Full text of "The American journal of roentgenology, radium therapy and nuclear medicine"

See other formats

Kiiia»iili!i':^t;;;«^i::

THE {^

AMERICAN JOURNAL
OF ROENTGENOLOGY

[founded in 1906 AS THE AMERICAN QUARTERLY OF ROENTGENOLOGY}

EDITED BY H. M. IMBODEN, M.D.

VOLUME VIII

1921

JANUARY TO DECEMBER

NEW YORK
PAUL B. HOEBER, PUBLISHER
1921

71. S.

V. 3

CONTENTS OF VOLUME VIII
ORIGINAL ARTICLES

Peristalsis in Health and Disease (First Caldwell
Lecture)

Pneumoperitoneum of the Pelvis: Gynecological
Studies

Treatment of Carcinoma of the Breast by Imbed-
ding Radium Supplemented by X-Ray
Dislocation of the Carpal Scaphoid . . .
X-Ray Treatment of Tonsils and Adenoids
An Inexpensive Radium Capsule Holder .
Two Unusual Chest Cases

Roentgenographic Studies of Bronchiectasis and
Lung Abscess after Direct Injection of Bis-
muth Mixture through the Bronchoscope

Bucky Diaphragm Principle Applied to Radiog-
raphy of the Spine

Pneumoperitoneum as an Aid in the Differential
Diagnosis of Diseases of the Left Half of the
Abdomen

Use of CO2 in Pneumoperitoneum

Traumatic Pneumocranium

A Retinometer

Intracranial Calcification . ,

New Roentgenographic Technique for the Study of
the Thyroid

The Diagnosis of Primary Tumors of the Lungs .

The Clinical Importance of the Different Types of
Pulmonary Tuberculosis as Determined by
Roentgen Examination

The Value of Lateral and Oblique Studies of the
Chest

A Simple and Practical Method for the Rapid
Hardening of Gas Tubes

Remarks on the Technique of the Roentgen Ex-
amination of the Kidneys

Subphrenic Pneumoperitoneum Produced by Intra-
uterine Insufflation of Oxygen as a Test of
Patency of the Fallopian Tubes in Sterility and
in Allied Gynecological Conditions . . . .

The Detection of Retroperitoneal Masses by the Aid
of Pneumoperitoneum .........

Walter C. Alvarez, M.D.
J. G. Van Zwaluwenhurg,
M.D. and
R. Peterson, M.D. . .

Russell H. Boggs, M.D.
T. S. Bonney, D.D.S. .
Wm. D. Witherhee, M.D
George E. Pfahler, M.D.
John G. Williams, M.D.

25
30
31

Henry L. Lynah, M.D., \
William H. Stezmrt, M.D. f ^^

Mollis E. Potter, M.D.

A. F. Tyler, M.D. . .
Walter C. Alvarez, M.D.
Alfred S.Doyle, M.D. .
A. Howard Pirie, M.D.
John T. Murphy, M.D.

George E. Pfahler, M.D.
Arthur C. Christie, M.D.

65
71

73
75

81
97

R. G. Allison, M.D. . . . 103

William A. Evans

106

Sidney H. Levy, M.D. . ]

and Hubert Mann, M.D. .] ^^^

IV.S. Lawrence, M.D. . . 115

/. C. Rubin, M.D., F.A.S. . 120
L. R. Sante, M.D. . . . 129

iy Contents

The Collateral Treatment of Malignant Patients

Undergoing Radiotherapy E. H. Skinner, M.D. . . 138

The Intralaryngeal Application of Radium for

Chronic Papillomata . Preston M. Hickey, M.D. . 155

Observations on the Behavior of the Normal Pyloric ( C. W. McClure, M.D., and \ j-g

Sphincter in Man \L. Reynolds, M.D. . . .) ^

Leather-Bottle Stomach (Linitis Plastica) .... Leon T. Le Wald, M.D. . 163

_ _ . , . , ^^ ^ ^ ( William F. Petersen, M.D. ^

Selective Organ Stimulation by A-Rays: Enzyme j ^^^ (^ ^

Mobilization | Clarence C. Saelhof, M.D. j

The Influence of X-Ray Organ Stimulation on the

Coagulative Mechanism Clarence C. Saelhof , M.D. . 179

An .Y-Ray Burn of Third Degree Followed by

Rapid Healing Edward S. Blaine, M.D. . 183

Hirschsprung's Disease James G. Ware, M.D. . . 186

Diagnosis of a Brain Tumor by Pneumoventriculog-

raphy A. S. Merrill, M.D. ... 188

Foreign Body in the Bronchus for Fifteen Years . . /. Seth Hirsch, M.D. . . 191

X-Ray Findings in the Chronic Gas Cases .... Henry C. Pillsbury, M.D. . 193

Practical Application of the Sphere Gap to Roent-
genotherapy H. J. Ullmann, M.D. . . 195

Value of Prophylactic X-Ray Treatments .... Samuel Stern, M.D. . . . 199

The Absorption of Radium Radiations by Tissues . . Gioacchino Failla, E.E. . 215

Personal Experiences with the Application of the

Newer Roentgen Therapy in Cancer M.J. Sittenfield, M.D. . . 232

-Clinical Results from the Newer Technique of Deep

Roentgenotherapy in Malignant Disease . . . George E. Pfahler, M.D. . 236

A New Device for Increasing the Protection of

Both the Patient and the Roentgenologist . . . George E. Pfahler, M.D. . 239

X-Ray Treatment of Pulmonary Tuberculosis . . . Will Wilkinson, M.D. . . 241

A Roentgen Study of Dust Inhalation in the Granite

Industry D. C. Jarvis, M.D 244

The X-Ray Shadows of Lung Syphilis and Syphi-
litic-Tuberculous Symbiosis in the Lungs . . . . W. Warner Watkins, M.D. 259

Aneurysm of the Aorta and Abscess of the Tracheo- ( R. D. Carman, M.D., and \ ^
bronchial Lymph Glands \C. G. Sutherland, M.D. . j ^ ^

{W. Edward Chamberlain,^
M.D., and V 272

R. R. Newell, M.D. . . J
Present Problems and Future Prospects of Deep

Roentgen Therapy Albert Soiland, M.D. . . 276

Relation of the Science of Physics to Radiation

Therapy Henry Schmits, M.D. . . 285

X-Ray Treatment of Hypertrophy of the Prostate . . Samuel Stern, M.D. . . 292

Roentgen Ray Cardiac Studies Charles L. Martin, M.D. . 295

Contents v

Analysis of Eleven Hundred Roentgen Examina-
tions of the Gastro-intestinal Tract Robert H. Lafferty, M.D. 315

319
321

328

Congenital Atresia of the Esophagus E. H. Skinner M.D. .

X-Ray Work from the Viewpoint of an Internist . . George Dock, M.D. . .

The Intensity of Scattered X-Rays in Radiography . R. B. Wilsey ....

Remarks on the Measurement of Scattered Radia-
tion Millard S. Hodgson . . 338

The Bucky Diaphragm H. W. Van Allen, M.D. . 340

Some Accessories to the Potter-Bucky Diaphragm . . David Ralph Bowen, M.D. 343

Studies in Reduction of Bone Density D. B. Phemister, M.D. . 355

Making and Filing of Records in the Section on

Roentgenology in the Mayo Clinic R. D. Carman, M.D. . . 372

Congenital Non-rotation of the Stomach Lyell C. Kinney, M.D. . 383

Transposed Viscera W. 0. Upson, M.D. . . 385

Diverticulum of the Lower Portion of the Esoph-
agus H. W. Dachtler .... 389

Total Radiation Falling on Surfaces Exposed to

Point Sources Julius Kaufman, M.D. . 390

X-Ray Spectra and the Structure of Matter . . . . J.M. Cork, M.S 393

Radiography of the Mastoid A. S. Macmillan, M.D. . 399

Head-Rest for the Roentgenography of the Acces-
sory Sinuses G. IV. Grier, M.D. . . . 402

Table Designed for the Simplification of Pneumo-
peritoneum Technique L. R. Sante, M.D. . . . 404

Use of Radium in the Treatment of Myxomatous

Nasal Polyps: Preliminary Report H. R. Lyons, M.D. . . . 407

X-Ray Examination of the Chest and an X-Ray

Classification of Pulmonary Tuberculosis . . . H. Kennon Dunham, M.D. 427

Gunshot Injuries to the Brain ........ Harold Swanherg, M.D. . 445

A Manometer and Flow Volumeter for Transuterine
Peritoneal Inflation to Determine Patency of
Fallopian Tubes in Cases of Sterility ..../. C. Rubin, M.D. . . . 459

Multiple Osteochondromata B. Pierre Widmann, M.D. 462

Super-radiation and Delayed Reactions Albert Soiland, M.D. . . 466

Roentgen Ray Treatment of Acne Vulgaris . . . ['^CM^fi^^Ma^^^^^^^

The X-Ray in Dermatology Guy C. Lane, M.D. . . . 476

Two Contrasting Cases: (i) Adenocarcinoma of

the Stomach Revealed by Roentgenograms but

not Palpable on Exploration by the Surgeon;

(2) Gastric Ulcer not Shown by the Roentgen

Ray, but Found at Operation Russell D. Carman, M.D. . 480

Hemangioma of the Duodenum Russell D. Carman, M.D. . 481

Report of a Case of Osteoma John H. Lambert, M.D. . 483

zH Contents

Some Recent Advances Made in France on the
Technique of the Roentgen Diagnosis of Dis-
eases of the Heart and its Vascular Pedicle . , Gonzales Martinez, M.D.

Tumors of Nerve Tissue in Relation to Treatment

by Radiation James Ewing, M.D. . .

Syphilis of the Lungs, its Radiographic Findings

and their Pathological Basis Ross Golden, M.D. . .

Fractures of the Pelvis . C. C. Grandy, M.D. .

Two Cases of Lymphatic Disease in the Same

Family, with Roentgen Findings Charles M. Richards, M.D

Gastrocolic Fistula L. B. Groeschel, M.D. .

The Roentgen Ray Treatment of the Eczema Group . F. J. Eichenlauh, M.D.

Some Remarks on the Present Status of X-Ray

Therapeutics George W. Holmes, M.D.

491

497

502

511

514
516
520

522

The Reduction of Radiographic Exposures to One ( n j ^ t M A \

Twenty-fifth of the Normal Amount by Means < ' r>' 1 ' ' > '>28

r , r Ar T^ -r.1 . I ct/w T. Thome Baker - . ( '^

of the Impex A-Ray Plate ^ ^

The Effect of Radium Emanation on the Adult

Mammalian Brain Halsey J. Bagg, Ph.D. . 536

An Unusual Case of Pulmonary Neoplasm . . . . J. S. Pritchard, M.D. . . 555
Dunham's Fans in a Roentgen- Ray Study of Granite

Dust Inhalation D. C. Jarvis, M.D. . . . 560

Report of a Case of Osteosarcoma L. B. Morrison, M.D. . . 565

Extra Bones, in the Wrist and Ankle Found by

Roentgen Rays A. Howard Pirie, M.D. . 569

Primary Sarcoma of the Vertebrae, With Report

of Four Cases Karl F. Kesmodel, M.D. . 573

My Studies on the Physical Foundations of Deep

Therapy Treatment Friedrich Dessauer, M.D. . 578

The Effects of Scattered X-Rays in Radiography . . R. B. Wilsey 589

The Kearsley StabiHzer W. D. Coolidge, Ph.D. . 599

A Suggestion for Improving the Visibility of the

Apical Field on the Chest Radiogram . . . . H. A. Bray, M.D. . . . 602

( Charles C. Norris, M.D., ^
A Histological Study of the Effects of Radium on I and V 604

Carcinoma of the Cervix ( A^. 5. Rothschild, M.D. J

A Simple Drying Rack for Films Amin Boutros, M.D. . . 608

A Preliminary Report on the Effects of Roentgen j Lloyd Bryan, M.D., and ) ^

Rays on Gastric Hyperacidity | Hugh F. Dormody, M.D. j ^

Treatment of Leukemia H. B. Thompson, M.D. . 629

Suboccipital Pott's Disease Charles M. Richards, M.D. 632

r R. G. Allison, M.D., A. H. "|
X-Ray Treatment of Toxic Goiter ...... ^ Beard, M.D., and G. A. V 635

( McKinley, M.D. . . . j •

Report of two Interesting Cases of Genito-Urinary

Pathology L. B. Groeschel, M.D. . . 641

Contents vii

Developmental Rests in Cecum and Ascending j R. A. Payne, M.D., and \ ^
Colon and their Roentgen-Ray Diagnosis . . } F. C. Trahar, M.D. . . / ^^

The Roentgenological Aspect of Sprengel's De-
formity Edivard S. Blaine, M.D. . 654

A Modification in Technique for Radiographing

Upper Molars C. A. Lemaster, D.D.S. . 659

X-Ray Report S. J. Young, M.D. . . 660

Radium Combined with X-Ray Treatment of Carci-
noma of the Breast George E. Pfahler, M.D. . 661

Radium in the Treatment of Carcinoma of the

Breast as an Adjunct to Surgery Ben R. Kirkendall, M.D. . 668

Dosage in Radium Therapy Gioacchino Failla, M.D. . 674

Benign and Malignant Gastric Ulcers from a Roent-
genologic Viewpoint Russell D. Carman, M.D. . 695

Roentgenological Studies of Infected Kidneys . . W. K. Lim, M.D. . . . 704

A Review on Three Years' Work and Articles on

Pneumoperitoneum James T. Case, M.D. . . 714

Observations on the Normally Developing Shoulder Isidore Cohn, M.D. . . . 721

Some Observations on the Treatment of Hyper-
thyroidism with X-Rays George W. Holmes, M.D. 730

Intensive X-Ray Therapy as seen practiced in the

Clinics in Europe Samuel Stern, M.D. . . 741

The Treatment of Cancer of the Rectum by Radium . Douglas Quick, M.D. . . 746

Pathological Classification of Thyroid Gland Di-
seases with Radium Treatment in Toxic Goiter . R. E. Loucks, M.D. . . . 755

American Literature on Radium and Radium Ther-
apy Prior to 1906 Carroll M. Chase, M.D. . 766

Preliminary Report on a New Tube for Producing

Duodenal Block . . . " R. G. Van Nuys, M.D. . 779

A Simple Device to Prevent tlie Omission of Filters

in Deep Roentgen Therapy George E. Pfahler, M.D. . 780

THE AMERICAN JOURNAL
OF ROENTGENOLOGY

Editor, H. M. Imhoden, M.D., 7\lew Tor\

VOL. VIII (new series)

JANUARY, 1 92 1

No. I

PERISTALSIS IN HEALTH AND DISEASE *t

First Caldwell Lecture

By WALTER C ALVAREZ, M.D.

Assistant Professor of Research Medicine, George Williams Hooper Foundation for Medical Research,

University of CaHfornia Aledical School

SAN FRANCISCO, CALIFORNIA

IX/TR. PRESIDENT, Members of The
■^^■^ American Roentgen Ray Society:
I wish first to thank you for the great honor
you have done me in asking me to give the
first Caldwell Lecture. It is a pleasure to join
with you in remembering the name of one
of the martyrs of medicine — a man who
gave his life for the advancement of science.
He was a pioneer, an inventor, a research
worker, a versatile, enthusiastic and lovable
man ; and we are all losers by his death. We
shall honor him best by carrying on the work
which he loved so much, and which meant
everything in life to him. I believe we shall
carry it on most rapidly when we do as he
did, when we venture out into "pure" science
— into physics, chemistry and engineering, to
improve our apparatus; and into biology,
physiology and bio-chemistry to explain our
findings in the body. How much more rap-
idly our transformers and tubes would have
been improved if there had been more men
like Caldwell at work in the field ; and how
glad we should be to-day that some manu-
facturers have at last seen the incalculable
benefits that can come through proper co-
operation with a physicist like Dr. Coolidge !

Every advance in technique brings its
problems of interpretation. I shall never for-
get my delight when, in 191 2, I got my first
radioscope from Vienna and saw the peris-
taltic waves coursing over the stomach. At
first it seemed as if all my desires had been
fulfilled, but in a few months this feeling of
satisfaction gave way to one of worry over
the many things which I saw but could not
interpret. I went East and told my troubles
to Cannon, who frankly admitted that many
of our pathologic findings are not explain-
able on the basis of the myenteric reflex or
the acid control of the pylorus. He gave me
room in the laboratory and told me to go to
work on these problems myself. He showed
me how to open an (anesthetized) animal's
abdomen under salt solution so that I could
watch the peristaltic movements. Two or
three days of this and I saw that the prob-
lems I had set for myself were too big and
too complicated. I was like a man who would
repair a wireless telephone without first
knowing the structure and inner workings of
the constituent batteries, induction coils, con-
densers and magnets. It was clear that I had
to begin back near the beginning, on prob-

•Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn., Sept. 14-17, 1920.
t This lecture will be published complete in book form by the publisher of The American Journal of Roentgenology.

Peristalsis in Health and Disease

lems which to an onlooker might appear to
have no promise of practical value. The in-
testine is a tube made up of smooth muscle
and it seemed to me that if I could learn
more about the properties and peculiarities
of that tissue I would come near to solving
some of the riddles of peristalsis. Hence it
is that for the last seven years I have turned
somewhat aside from the clinical journals
and have delved into the literature of the
experimental zoologists, the physiologists
and the comparative anatomists. I have
studied smooth muscle in organs other than
the bowel — in the bladder, the ureter, the
vas deferens, the uterus, the arteries and the
iris. Many helpful suggestions have been
gotten from studies on snails, sea-cucum-
bers, anemones, jelly fishes, clams, worms
and crayfishes. I have found the medical in-
dexes almost useless in this w^ork, because
the most helpful articles are often concealed
behind the most uninviting titles. Thus, who
would have expected to find an explanation
for the gastric upsets of fevers and asthenic
states in an article on the swimming plates
of a tiny water organism? — yet there I be-
lieve it is. The author is Professor Child, a
zoologist, and the article is entitled, "The
Gradient in Susceptibility to Cyanides in the
Meridional Conducting Path of the Cteno-
phore Mnemiopsis." ^

It is unfortunate that we practicing physi-
cians must often miss the most thought-
stimulating articles because they are buried
awa)^ in the highly technical journals which
we do not ordinarily read. Some day we may
have a better abstracting service, but in the
meantime we shall probably have to do
occasionally as the Israelites did when they
approached the Promised Land; we shall
have to send out spies to look over this field
which we ourselves have so little time to ex-
plore, and to bring back some of the fruits.
When asked to speak before you to-day, it
seemed to me that the best service I could
render would be to bring to you some of the
ideas which I, a practicing physician and
radiographer, have gotten during my so-
journ among the physiologists.

THE AUTONOMY OF MANY PARTS OF
THE BODY

The first of these ideas is that the forces
zvhic/i bring about, modify and control peris-
talsis must be looked for mainly within the
zualls of the gut itself. I cannot too strongly
emphasize this point, because it seems to me
that the failure to grasp it is the greatest
stumbling block to further advance in the
knowledge of our subject. Whenever I de-
scribe some of the regional differences in be-
havior which can easily be demonstrated in
the excised stomach and bowel, someone is
almost sure to say: "Oh, that is due simply
to the autonomic and the sympathetic." An-
other settles the whole problem by calling it
a "Reflex." When I point out that the pecu-
liarities persist in little pieces of muscle
which have been cut out and kept in the ice
box for several days, these individuals still
ascribe everything to the activities of the
canny little ganglion cells in Auerbach's
plexus.

Now, the most paralyzing thing in scien-
tific work is a facile explanation which puts
a stop to further curiosity without really ad-
vancing our knowledge of the subject; and I
have never been able to see the value of
pushing the explanation for a mechanical
phenomenon out of the organ in which it
might be studied, and into a tiny ganglion
where we can hardly follow it. It seems to
me that many even of the teachers of physi-
ology have a wrong idea of the nervous sys-
tem and its relation to the viscera. They look
at it somewhat as an electrical power house
which not only supplies the motive force but
controls the activities of the various trains
running over a railroad. My ana^T^sis of the
literature makes me feel that we should look
at it more as a telephone switchboard with
wires which carry nothing but messages of
warning and advice from one engineer to
another. The trains supply their own
power; and the differences in speed and
other activities are due to peculiarities
in fuel, differences in the gradient of the
road. etc.

Peristalsis in Health and Disease

Anyone who will study the behavior of
the lower forms of life before and after re-
moval of their nervous systems will see that
the nerves are there primarily to expedite
conduction. The ganglionic cells are nutri-
tional centers and not storehouses of wisdom
and power. Some of the most complicated
"reflexes" are performed by decerebrate ani-
mals or by excised parts of these animals.
Loeb, Parker and others have shown clearly
that the mechanisms are local and compara-
tively simple.

THE MYOGENIC NATURE OF THE RHYTHMIC
CONTRACTIONS

Similarly, in the gastro-intestinal tract we
find that after the preliminary shock has
worn off, digestion goes on quite normally
after complete section of the vagi and the
splanchnics. We get good peristalsis in the
stomach and intestine that have been re-
moved from the body and either perfused or
placed in oxygenated Locke's solution. We
get active peristalsis in small segments of
gut and in pieces of muscle stripped from
the wall. It is clear then that the gastro-intes-
tinal tract is autonomous; it carries within
itself all the mechanisms essential to peris-
talsis.

The next cpiestion is, what part is played
by the muscle and what part by Auerbach's
plexus? Practically all writers on the subject
state that the rhythmic contractions are due
to stimuli coming from the ganglion cells
of the plexus. They base this opinion on the
first few papers by Magnus, who found that
strips of circular muscle from which the
plexus had been removed did not contract
rhythmically. Unfortunately no one seems
to have noticed that In his fifth paper,^ Mag-
nus admits that these same plexus-free strips
did beat when he added a little physostigmin,
strophanthin or barium to the solution.
Moreover, no one notices the work of Gunn
and Underbill ^ who repeated these experi-
ments, and by taking greater precautions to
avoid trauma, obtained plexus-free strips
which would contract rhvthmicallv without

the help of tonic drugs. This is what we
should expect, because it has been well
proven in many ways that rhythmic contrac-
tion is a function of muscle itself.

It is clear then that the man who would
understand peristalsis and the various ac-
tivities of the stomach and bowel must pay
particular attention to the properties and re-
actions of the gastro-intestinal muscle. Some
may ask: what then is Auerbach's plexus
good for? It almost undoubtedly serves for
the conduction of stimuli and the coordina-
tion of movements ; it enables the muscle to
respond properly to stimuli coming from the
underlying mucous membrane, and it helps
in some way to keep that muscle from con-
tracting down into a hard knot. Such con-
tractions are well known to biologists, and
somewhat resemble the spastic paralyses of
striated muscles.

THE AUTONOMIC AND THE SYMPATHETIC

The next question is: what is the signifi-
cance of the vagus and sympathetic nerves
running to the intestine? The average clini-
cal writer to-day states that the autonomic
(vagi and sacral nerves) stimulate, and the
sympathetic fibers inhibit the intestine. Dis-
ease is supposed to follow an unbalance be-
tween these two effects. This unbalance can
be diagnosed and corrected by the use of
certain drugs which are supposed to be elec-
tive in their actions. These theories of vago-
tonia and sympathicotonia have had a
strange fascination for the rhedical mind;
they have been dragged in with the utmost
assurance to explain all sorts of disease
states; and I believe have had a most unfor-
tunate influence on our conceptions of gas-
tro-intestinal physiology. It may be that
these theories will eventually prove useful;
but in my opinion their foundations are so
shaky that some day the whole edifice is
going to go. In the following brief discus-
sion I can only point out a few places in
which the proponents of these theories have
made things much simpler than they really
are.

Peristalsis in Health and Disease

Although in the main, the vagus tends to
stimulate and the sympathetic to inhibit the
stomach and bowel, these effects are gener-
ally transient, often indecisive and not infre-
quently reversed. They vary with the
strength of the stimulus and with the con-
dition of the muscle. The next objection is
that the whole theory of "nerve endings"
and "intermediate substances" is shaky.
Leading pharmacologists have for some time
been calling attention to the many contra-
dictions in the literature of the subject, and
have warned us to be careful in accepting
physiologic conclusions based upon the sup-
posed activities of the various nerve pois-
ons.*

Perhaps the strongest objection to the re-
cently revived theories in regard to the
autonomic and sympathetic systems is that
they make it appear that the sympathetic
nerves with the celiac ganglia constitute a
separate and distinct brain system which can
be antagonistic to, or out of harmony with
the central nervous system. This view is en-
tirely at variance with the facts, which have
beien collected and discussed in a masterly
way by Gaskell in his monograph on "The
Involuntary Nervous System."^ He shows
that the involuntary nerves and ganglia are a
part of the central nervous system ; they are
connected with it just as the voluntary
nerves are, and they have developed from
the same embryonic cells. The main differ-
ence is simply that the motor ganglia which
in the voluntary system are found in the an-
terior horns of the cord, have migrated,
some as far as the paravertebral ganglionic
chain ; some into the solar plexus, and some
into the nerve nets in the walls of the hollow
organs. Hence it is that the rami communi-
cantes or preganglionic fibers in the sympa-
thetic system, and most of the efferent fibers
in the vagus are simply elongated connector
neurones such as we find between the motor
and sensory roots in the cord, and in the
pyramidal tracts. Furthermore, it has been
shown that there are no commissural fibers
between the different sets of sympathetic
ganglia such as would have to be present if

these ganglia were to mediate reflexes like
an abdominal brain.

VALUE OF THE EXTRINSIC NERVES

We learn then from Gaskell the same les-
son that we have had from Loeb and from
Parker; that the nerves are there to conduct,
and not to exercise faculties requiring almost
human intelligence. There are times when
the animal as a whole needs to communicate
with its digestive tract; there are times also
when the tract must communicate with the
body. There are many times when one end
of the tract must communicate with the
other ; and on all these occasions the extrin-
sic nerves come into play. The vagi carry
feelings of hunger and of satiety from the
stomach to the brain ; they help in adjusting
the tone of the stomach wall to the food
coming down the esophagus ; and they carry
the stimuli that give rise to the psychic se-
cretion of gastric juice. If the food must be
rejected by vomiting they carry the impulses
which bring the abdominal muscles to the
aid of the stomach. They probably carry
messages from the digesting tract which
make the animal feel comfortable and sleepy.
The splanchnics serve largely to quiet the
tract and to stop digestion when the body is
distressed or injured. The extrinsic nerves
probably have much to do with the digestive
upsets with disease elsewhere in the body;
but we shall see later that these changes can
be accounted for also by actual damage to
the gastro-intestinal muscle.®

I regret that I have had to spend so much
time on this subject of nervous control; but
it seems that the human mind is not so ready
to look for new explanations for well-
known phenomena, or even to accept them
when found, until its contentment with the
old explanations has been disturbed. Now
that we see how autonomous the tract is and
how dangerous it is to rely on theories of
ganglionic control, we should be the more
eager to learn all we can about the gastro-
intestinal muscle.

Peristalsis in Health and Disease

SMOOTH MUSCLE

As you know, smooth muscle is made up
of spindle-shaped cells which vary in size,
shape, number of nuclei, etc., in different
animals and in different parts of the same
animal. As a rule it contracts more slug-
gishly than striated muscle does; it takes
longer to get started, and it is slower in re-
covering its original length. After a number
of strong stimuli or sometimes after only
one, it may become quite refractory. After a
long rest it may seem to get on a hair trig-
ger again so that it responds powerfully and
explosively to a slight stimulus. That is the
condition of the digestive tract after the
night's rest ; and it probably has much to do
with the fact that most of us have the daily
bowel movement in the morning, imme-
diately after breakfast. With an animal open
under salt solution, one can often start a
rush wave down the bowel by pinching the
duodenum. For some time afterwards, simi-
lar pinches will have no effect, but if we wait
long enough we will again find the bowel so
sensitive that the slightest stimiulus will
start a wave.

Another characteristic of smooth muscle
is its ability to maintain a firm and lasting
contraction without fatigue. We see this in
the muscles which close the shells of bivalves
and we see it in the wall of the colon. It is
interesting that the muscle in a bivalve con-
sists of two parts: one which closes the shell
and the other which locks it closed. By cut-
ting first one and then the other it can be
shown that neither one can do the work of
the other. Similarly, if one of you will try
to hold his arm out perpendicularly to his
body he will soon find it a most painful and
fatiguing experiment. The deltoid was not
designed for sUch heavy work, but the glutei
and back muscles are carrying much heavier
loads all day, and they do not complain.
There are all kinds of muscles, all suited to
different purposes. Some, like those in the
wings of insects, must contract 300 times a
second; others like those in the wings of a
hen have little to do. Those who think all

muscle is the same forget the diffenences be-
tween the white and dark meats of chicken,
between the heart and the gizzard; between
the tenderloin, roundsteak and tongue. I
have gone into these differences so at length
to prepare you for the thought that there are
big differences between the muscle in the
cardiac and pyloric ends of the stomach;'
between that in the small intestine and that
m the cecum « and colon." The muscle on the
lesser curvature near the cardia is soft to
the touch like coagulated fibrin ; that in the
pyloric antrum is tough like gizzard and has
a different color. Stimulate the two with an
electric current or with a pinch and you get
two entirely different contraction curves;
put them into warm oxygenated Locke's so-
lution and you get two different types of
rhythmic activity. These differences were to
be expected when we remember that the up-
per and lower ends of the stomach have
different kinds of work to do. The upper end
serves largely as a hopper to hold the food;
the lower is the mill that does the heavy
work. More of these local peculiarities will
be described later.

Another characteristic of smooth muscle
in hollow organs is its responsiveness to ten-
sion. Most of the manifestations of peris-
talsis are brought about and regulated
largely by the internal pressure due to the
presence of food or gas. Cannon has shown
that the rhythmic segmentation in the small
intestine is due simply to the fact that those
muscle fibers which are stretched tend to
contract.

Smooth muscle shortens also under the in-
fluence of direct irritation. Thus we find
contraction of the cardia, pylorus, ileo-cecal
sphincter and anus when there is ulceration
or inflammation near by. We find hour-glass
contractions of the stomach opposite ulcers
on the lesser curvature; and shrunken and
irritable duodenal caps with ulcers in that
region.

PERISTALSIS

If we stimulate the smooth muscle in a
tubular organ like the intestine or ureter, we

Peristalsis in Health and Disease

get a contraction which produces a tonic
ring. From this ring, waves are given off in
both directions. They remind one of the
ripples which arise at a point where a stone
has been thrown into a pond. The impulse
spreads from muscle fiber to muscle fiber,
and need not be mediated by nerves, ganglia,
centers or reflexes. I have observed, after
electrical stimulation, similar waves spread-
ing both ways along the segments of a re-
cently voided tapeworm; and I have seen
them traveling away from the ridge which
forms when one strikes the irritable pectoral
muscles of a consumptive. It seems to me
that the stimulus probablv increases the
chemical activity at the point where the
tonus ring forms; it raises the metabolic
rate, and stimuli spread out on both sides
down gradients of chemical activity.

GRADIENTS

Returning to the simile of waves spread-
ing in water, it seems to me that some tu-
bular organs may be likened to ponds which
are level to begin with ; others are more like
rivers which have deiinitely established gra-
dients. In the first case the waves spread
equally well in all directions; in the second,
the waves spread better down stream than
up. Perhaps I can illustrate my point best
by showing the evolution of the fixed
gradient in the heart. As you know, in that
organ the beat follows a gradient of rhyth-
micity from the sinus to the ventricle. It was
Gaskell who showed that if we cut a heart
into three or four pieces the one containing
the mouths of the great veins will show the
greatest tendency to beat rhythmically, and
will have the fastest rate. The ventricle will
be slow to start beating and will have a slow
rate. Now, when we turn to the primitive
heart of the sea slug (aplysia), we find a
tube which apparently has no constant
gradient in either direction. Its beat arises
now on one side and now on the other, de-
pending on where the blood produces the
greatest tension. Hunter could find no sign
of a gradient in the heart of one of the

ascidians. In these animals the beat runs for
a while towards the viscera and then for
a while towards the gills. The pace-making
end seems to get fatigued ; its rate is slowed
and finally the other end is able to assume
the pace for awhile. A constant direction of
contraction may be maintained by electrical
stimulation of either end of such a heart. It
seems to me that Hecht's ^° studies on ascidia
atra show us the very beginning of the fixed
gradient which we find in the hearts of the
higher animals. He found that although the
heart of the ascidian reverses its beat from
time to time, the sum of the advisceral beats
is about twice that of the abvisceral. More-
over, as we should expect if the gradient is
a little better in the advisceral direction, the
rate of conduction is definitely faster in that
direction than in the other. If a wave is
started in the middle of the heart going both
wa3's it tends to efface the abvisceral waves
which according to our theory would have
the smaller momentum. It is interesting also
that under slightly adverse conditions, as af-
ter warming the water or after diluting or
concentrating it, it is the i abvisceral beat
which is suppressed. We find a little more
stable, but still reversible heartbeat in the
sharks and rays. In them the slightest stimu-
lus to the bulbus aortae will reverse the beat
and the same stimulus to the sinus will re-
store it. Even in the higher vertebrates the
heartbeat can be reversed temporarily by
agencies which lower the rhythmicity of the
auricle or raise that of the ventricle.

There is considerable evidence now that
peristalsis in the ureter follows a gradient
of rhythmicity from the kidney to the blad-
der," and I have been collecting data which
suggest that there are similar gradients in
the vas deferens and the fallopian tubes. We
mav perhaps be able later to state it as a law
that the direction of transport of material in
a tubular organ depends on gradients of
rhythmicity, tone,, irritability and metabol-
ism. When we come to think of it, our ex-
perience with engineering and mechanics
should have led us long ago to look for grad-
ients in these muscular tubes. We know that

Peristalsis in Health and Disease

water in a pipe follows gradients of gravity
or of pumping pressure; electricity flows
along gradients of voltage, the winds fol-
low gradients of barometric pressure, etc.

GRADIENT IN THE INTESTINE

Now what evidence have we that there is
a gradient in the gastro-intestinal tract? As
far as rhythmicity goes the evidence is over-
whelming. It is a simple thing to open an
animal (rabbit) under salt solution and to
demonstrate that the rate of rhythmic con-
traction varies from about 20 per minute in
the duodenum to 10 per minute in the lower
ileum. It is easy also to cut out short seg-
ments of the bowel and to show that their
rate of rhythmic contraction continues to
vary inversely as the distance from the py-
lorus. A similar gradient can be shown in
strips of muscle excised from the wall of the
stomach. The fastest rate is found in the
strip from the lesser curvature near the
cardia. It is harder to show the gradient in
the colon, but that was to be expected. Re-
member that the large bowel is more slug-
gish than the small ; it lets the contents lie in
one place for long periods of time and waves
can go in either direction over the cecum
and ascending colon. Hence it is that the
excised muscle is slow to start beating, its
rate is slow; it tends to contract down into
a hard knot and stay that way ; and the gra-
dient is poor and often reversed. In the small
intestine of the rabbit and white rat the
rhythmic gradient is so fixed, and so inti-
mately "built into" the structure of the in-
testine that one can determine the oral and
aboral ends of short excised segments by
counting the rates at the two ends. It has
been shown also that when sections of small
intestine are cut, turned end for end and
anastomosed again, they will transport
liquids but not solids, because the original
direction of peristalsis is maintained as long
as the animal lives. This experiment shows
that the gradient is basic and not the result
of functional adaptation. Further evidence
for that conclusion is found in the fact that

it is just as marked in the fetal intestine,
which has not yet functioned, as in the adult
animal. The permanence of the gradient in
the gut is to be expected from studies on the
lower forms of life. The mouth of a frog is
lined by epithelium covered with little cilia
which wave in one direction. If a piece of
this epithelium is cut out, turned through an
angle of 180°, and grafted back again, the
cilia continue to beat in their original direc-
tion, now contrary to that in the rest of the
mouth. In some of the worms the so-called
"polarization" is so perfect that if the ani-
mal is cut into a half-dozen pieces they will
all crawl in the same direction towards the
point where the head used to be.

Before leaving the topic of rhythmic con-
traction I must make it clear that in the in-
testine the rhythm of one segment rarely
influences the rhythm of the adjacent ones.
As you know, in the heart the region with
the fastest rate sets the pace for all others,
and the wave of excitation travels so rapidly
that to the naked eye the mammalian heart
appears to contract simultaneously all over.
In the stomach, the area with the most rapid
rate at the cardia sets the pace, and we can
see the waves traveling slowly to the pylorus.
In the small intestine each segment contracts
at its own rate and only occasionally do we
see what are called peristaltic rushes run-
ning any distance down the bowel. Although
the duodenal muscle has the fastest rate it
does not set the pace for the rest of the gut.
I must emphasize this point because some
writers in overlooking it, have theorized un-
warrantably on the basis of some purely
anatomical observations reported by Keith.

UNDERLYING BASIS OF THE RHYTHMIC
GRADIENT

The next question is: how are these dif-
ferences in rate brought about? What are
thev due to? What are the structural dif-
ferences behind them ? As we have seen that
these rhythmic movements are myogenic in
origin, it is plain that we must look for the
differences in the muscle. Now, it has been

Peristalsis in Health and Disease

shown that the rate of rhythmic contraction
is probably dependent upon the rate at which
the chemical processes go on. Some sub-
stance is built up to a certain point and then
exploded to produce the contraction. If the
metabolism is slow it should take longer to
complete the cycle. We know also that
warming hastens chemical processes, and
Taylor and I have shown that warming the
intestine hastens the rate of rhythmic con-
traction. As we can take a piece of ileum
beating lo times a minute, and by warming
it speed up its metabolism so that it will beat
ly times per minute, it seems to me that the
duodenum which normally beats ly times
per minute must have a faster metabolic
rate than the ileum. Such differences in
metabolic rate have been demonstrated in
other organs of the body, where they ap-
pear to have great significance.^' During the
last few years Miss Starkweather and I have
brought forward a good deal of evidence to
show that there is a gradient of oxidation
from the cardia to the pylorus, from the
duodenum to the ileum and from the ileo-
cecal sphincter to the anus.^^ For the unit of
weight and time the muscle from the duode-
num gives off more CO2 than does the
muscle from the ileum. This is true not only
for the active but also for the resting muscle.
Graded differences have been found, more-
over, in the catalase content of equal w^eights
of minced muscle. This catalase, which lib-
erates oxygen from hydrogen peroxid, is
supposed by some to be an index of the rate
of metabolism ; and certainly in the bowel the
gradients of CO2 production and catalase
activity run very close together. Be that as
it may. the interesting thing to me is that
we can show a definite chemical difference
between the muscle in the duodenum and
that in the ileum. ^

We know that there is some gradation
also in the irritability of the intestine as re-
gards distension. The duodenum and je-
junum are ver\'' responsive to the presence
of food or balloons, while the lower ileum
and colon are quite tolerant of them. You
all know that the barium meal in the je-

junum appears in small flecks as if it had
been sprayed over the folds of the mucous
membrane. In the ileum it forms dense saus-
age-shaped masses. That is due simply to
the greater irritability and activity of the
upper bowel.

Hess showed years ago that the pull ex-
erted by the jejunum of a dog on a small
balloon is 228 gm., while in the ileum it is
75 gm. Naturally, the food is going to move
from the active and irritable regions to the
more sluggish and insensitive ones. I cannot
conceive of a simpler theory of peristalsis,
or one more in harmony with the laws of
physics and mechanics.

DIFFEREXCES IN PERISTALSIS IN DIFFERENT
PARTS OF THE GUT

Let US follow for a few moments the
progress of a barium meal through the di-
gestive tract, noting how the peristaltic
movements are influenced by local differ-
ences in structure and musculature. The
mouthful shoots through the first part of the
esophagus because the muscle is quick-acting
and striated. In the lower third the muscle
is largely of the smooth variety and progress
slows up. In the stomach the waves begin
probably in the pacemaking region near the
cardia and travel as shallow ripples until
either proper pressure conditions or the pres-
ence of the peculiar antral muscle causes
them to break into deep waves. If the tone of
the stomach is too high the waves may be
very shallow or hard to see; if the tone is
poor, we may see the best waves at the be-
ginning of the examination when there is
only a little food present and the muscle
fibers are not too badly stretched.

The waves do not cross the pylorus, prob-
ably because of the connective tissue barrier
there, the peculiar arrangement of the
muscle fibers, and the sudden transition to a
different type of muscle. The control of the
pylorus is parth' chemical and partly me-
chanical. Cannon has shown that the pres-
ence of acid above tends to relax the sphinc-
ter and acid below tends to close it. We know

Peristalsis in Health and Disease

however that this mechanism will not
explain the vagaries of pyloric action in
achylia gastrica, in duodenal ulcer, car-
cinoma, etc. We know also that the mere
presence of food or of a distending balloon
in the duodenum and jejunum will tend to
stop the progress of food through the py-
lorus." It is this mechanism that keeps the
stomach from emptying too rapidly after
pylorectomies, Mayo-Polya operations and
gastro-enterostomies. This holding back
above an active or distended part of the gut
is easily explained on the basis of changes
in the gradient. The digesting, stretched
bowel has a faster metabolic rate and a more
rapid rate of rhythmic contraction ; hence the
gradient is likely to be uphill towards it. This
will tend to slow the progress of more food
coming down from above.^^

The duodenal cap remains filled and
shows almost no peristalsis, probably be-
cause the muscle removed from that region
shows very little rhythmicity. There is some
evidence that the muscle fibers are arranged
in festoons and not circularly and longitud-
inally, as they are elsewhere. This might also
tend to modify the contractions. I think the
peculiarities of the upper duodenal regions,
together with a number of its pathological
tendencies, can be traced back to the great
specialization and complexity of this part of
the bowel in some of the fishes.

As I have already stated, the jejunum is
jejune or empty because of its great irrita-
bility and rapid peristaltic rate. The food
slows up in the terminal ileum because the
muscle is more sluggish and because the gra-
dient is uphill for a short distance to the ileo-
cecal sphincter.

In the first third of the colon the gradient
is poor, so that the waves can go in either
direction. In the rat they tend to be anti-
peristaltic when the feces are liquid and per-
istaltic when the feces become drier. The col-
onic contents move slowly because the
muscle is more sluggish and perhaps because
the gradient is poor. The tendency for the
feces to stay out of the rectum can be ex-
plained if I am right in thinking that the gra-

dient is uphill in that region. There is some
evidence from animal experimentation in
favor of that assumption."

PRACTICAL VALUE OF THE GRADIENT THEORY

This idea of a gradient underlying peris-
talsis gives us facile explanations for many
of the phenomena observed in disease. The
gradient of forces can be steepened, flattened
or reversed. A duodenal ulcer which raises
the irritability and tone of the upper end of
the tract often hurries the progress of food
through the small intestine; a lesion in the
appendix or cecum which raises the irritabil-
ity of the lower end of the bowel slows the
current and produces ileal stasis. A fissure in
the rectum may cause back pressure into the
cecum with constipation. A patch of enteritis
in the jejunum can reverse the current
above, in the duodenum and stomach — with
vomiting; and can hurry it below — with
diarrhoea. A stimulus reaching the jejunum
from the brain by way of the vagi — as in
sea-sickness — may also empty the tract both
ways. The distension of any part of the tract
by food raises the tone and irritability of
that region and tends to hold back the ma-
terial coming down from above.

Theoretically, the gradient can be reversed
not only by raising the lower end, but by
depressing the upper end. My observations
on excised segments of intestine from dis-
tempered dogs and snuffling cats agree
closely with those of Child on the lower
forms of life in showing that the most sensi-
tive regions, which have the fastest met-
abolic rates and the greatest need for oxy-
gen, are injured most by asphyxia, by many
drugs and by disease toxins. I have shown
repeatedly that a poison can be administered
in such dosage as to have no effect on the
colon and ileum, while it paralyzes the
duodenum and weakens the jejunum. Fur-
thermore, exised segments of duodenum
from a sickly rabbit may not contract at all
in Locke's solution when similar segments
from the ileum of that animal show no sign
of toxic influence. A reversal or a flattening

Peristalsis in Health and Disease

of the chemical gradients can also be shown
in many of the sick animals. We have here,
then, an easy and very simple explanation
for the digestive upsets with intestinal
stasis which we see in fevers and asthenic
states.

As I have discussed the practical aspects of
my theory in previous papers ^^ I will not go
into the subject any further at this time. Re-
member, when confronted by an abnormality
in intestinal peristalsis, that if the lesion is
sufficiently irritating it will raise the local
tone; this will reverse the gradient leading
to the lesion on the orad side and it will
steepen the gradient on the caudad side.
Hence it is that it may slow, stop or reverse
the progress of material coming toward it
from above, and may hasten the progress of
material that has passed it. Exceptions to
this rule will be found around the stomach
where there are many complicating factors
not sufficiently understood at present.

In closing, I liiust admit that with all the
work that has been done we still know too
little about the origin of many of the dis-
turbances of function which we see in our
patients — the hypo- and hypermotilities, the
sphincter spasms and the peculiarities in
gastric peristalsis. We must keep in mind
that we are using a physiologic method, bor-
rowed from Cannon ; we must think more in
terms of deranged physiology, and must not
rest too satisfied with the demonstration of
beautiful morphologic defects — ulcer cra-
ters, carcinomas, adhesions and displace-
ments. A number of you — practising radio-
graphers— have made excellent physiologic
studies on man; studies that are as much
pure physiology as those of Cannon and
Carlson. Much remains to be done; and if
my little message from the biologists to-day
should contribute anything to your zeal and
skill in attacking these problems I shall be
happy.

SUMMARY

We often fail in trying to solve our prac-
tical problems because we do not begin near

enough to the beginning. We must know
more about general principles and the work-
ings of small parts of the digestive tube.

We must venture out more into "pure"
science. We can get much help and inspira-
tion from the experimental zoologists and
the physiologists.

The digestive tract is largely autonomous,
and the forces underlying peristalsis must be
looked for mainly within the gut itself.

The tendency of writers to explain every-
thing on the basis of nervous reflexes and
ganglionic control is unfortunate, and para-
l3^zing to further progress.

Recent biologic work has shown in num-
berless ways that the main function of the
nervous system is conduction.

It has been shown conclusively that the
rhythmical contractions of the intestinal
muscle are myogenic in origin.

Auerbach's plexus serves to conduct stim-
uli and to coordinate the activities of differ-
ent parts of the tract. It contains no reflex
arcs.

Current theories about the antagonism be-
tween the vagus and sympathetic are shown
to be pseudoscientific, and out of harmony
with the facts as determined by the leading
anatomists and physiologists of the world
to-day. The sympathetic is an integral part
of the central nervous system and not an
outlying antagonistic "brain."

Many of the conclusions based upon the
supposed actions of drugs on nerve-endings
and "intermediate substances" must be re-
vised in the light of recent work.

The extrinsic nerves of the intestine serve
to communicate between the body and the
bowel, and between the bowel and the brain.

The digestive tract can work quite nor-
mally after section of all the extrinsic
nerves.

The key to an understanding of peristalsis
is to be found in a study of the smooth
muscle in the wall of the bowel.

There are different types of muscle suited
to different functions in the different parts
of the body and in different parts of the di-
srestive tract.

Peristalsis in Health and Disease

The properties of smooth muscle are dis-
cussed: its reactions to stimulation, to dis-
tension, inflammation, etc.

A peristaltic wave spreads 1)oth ways from
a stimulated spot like ripples from a stone
thrown into a pond. Most of the muscular
tubes are so constructed that the ripples can
travel in one direction better than another.

It may perhaps be a law for all tubular
organs that the transport of material in one
direction depends upon gradients of rhyth-
micity, irritability, tone and metabolism.

Such gradients can easily be demonstrated
in the walls of the stomach and intestine.

A bolus moves aborally in the digestive
tract because the pressure is greater on the
upper than on the lower side. This difference
in pressure is due probabh' to the graded
characteristics of the muscle.

The peculiarities of peristalsis in differ-
ent parts of the tract are explainable on the
basis of local differences in the structure of
the neuromuscular mechanism.

It is shown how the gradients may be up-
set in disease, and how these theories can
explain pathologic phenomena.

BIBLIOGRAPHY

1. Child. Am. J. Physiol., 1917, xliii, 87.

2. Magnus. Arch f. d. ges. Physiol., 1904, cii, 150,

361 ; 1905, cviii, 27-61.

3. GuNN AXD Underhill. Quart J. E.vpcr. Physiol.,

1914, viii, 275.

4. CusHXY. /. Physiol., 1910, xli, 2;^^; also Lancet,

1916, ii, 459; Edmuxds. /. Pharmacol. & Ex-
pcr. Therap., 1920, xv, 201 ; Gunn and Un-
derhill. Quart. J, Exper. Physiol., 1914, vi'i,
275 ; Cathcart and Clark. /. Physiol., 1915,
1, 119; Benczur. Internal Beitr. z. Path. u.
Ther. d. Erncihrungstor, 1910, i, 27 ; Boruttau.
Zentralbl. f. Physiol., 1916, xxxi, 303; Lang-
ley. /. Physiol., 1908, xxxvii, 300.

5. Gaskell. The Involuntary Nervous System, Lon-

don, 1916.

6. Alvarez. J. Am. M. Assn., 1919, Ixxiii, 1438;

Am. J. Physiol., 1918, xlv, 346.

7. Alvarez. Am. J. Physiol., 1916, xl, 585 ; Ibid.,

1916, xli, 321; Ibid, 1917, xHi, 422; Ibid, I917,
xlii, 435-

8. Alvarez and Starkweather. Am. J. Physiol.,

1918, xlvi, 563.

9. Alvarez. Am. J. Physiol., 1918, xlv, 342.
ID. Hecht. Am.. J. Physiol., 1918, xlv, 157.

11. Penfield. Am. J. M. Sc, 1920, clx, 36; Lucas.

.Im. J. Physiol., 1906-07, xvii, 392; Sokoloff
AND LucHsiNGER. Arch. f. d. ges. Physiol.,
1881, xxvi, 466; Satani. Am. J. Physiol., 1919,
xlix, 474; Weinstock AND O'Connor. Johns
Hopkins Hosp. Bull., 1920, xxxi, 197.

12. Child. Senescence and Rejuvenescence. Chicago,

1915-

13. Alvarez and Starkweather. A)n. J. Physiol.,
1918, xlvi, 186.

14. Alvarez. /. Arn. M. Assn., 1915, Ixv, 390.

15. Alvarez. /. Am. M. Assn., 1915, Ixv, 389.

16. Alvarez. Am. J. Physiol., 1915, xxxvii, 270; see

also RoST. Verhandl. d. deutsch. Gesellsch. f.
Chir., igi2, 169.

17. Alvarez. /. Am. M. Assn., 191 7, Ixix, 2018; Ibid,

1919, Ixxiii, 1438; /. Pharmacol. & Exper.
Therap., 1918, xii, 171.

PNEUMOPERITONEUM OF THE PELVIS*

GYNECOLOGICAL STUDIES -A PRELIMINARY REPORT

By JAMES G. VAN ZWALUWENBURG, M.D.

AND

REUBEN PETERSON, M.D., F.A.C.S.

University Hospital, University of Michigan

ANN ARBOR, MICHIGAN

AVERY fortunate and brilliant stereo set
of the pelvis in a case coming from an-
other ward was the means of interesting
Dr. Reuben Peterson, Professor of Obstet-
rics and Gynecology at the University Hos-
pital, in this study, and it is due largely to
his hearty and enthusiastic cooperation that
work was undertaken on this subject and
the present series of cases made possible. He
immediately suggested the possibilities of
this method for the illustration of clinical
lectures and the study of the anatomical rela-
tionship of the normal and pathological pel-
vis, quite aside from the possibility of the
development of" any diagnostic value. As a
further piece of good fortune, one of the
earliest cases provided such illuminating evi-
dence, even though it was poorly understood
at the time,that a serious attempt to develop
the diagnostic feature of the method was
projected.

At the outset it was agreed that if the
method were to have any extended useful-
ness the technicjue must be at once safe,
simple, certain and cheap ; and throughout
we have aimed to produce a method and a
procedure which can be reduced to a routine
and can be carried out by the assistants in
the Department of Gynecology and the lay
members of the radiographic staff. Natur-
ally, our first efforts were far from simple
and still farther from certain. In the interest
of safety, Dr. Peterson agreed to attend per-
sonally to the inflations during the develop-
mental stage, and to date we have examined
somewhat over forty cases without any
unexpected or disagreeable complications.

At the present time we have tentatively

adopted the following procedure: The pa-
tients are inflated in the examining room in
the Department of Gynecology immediately
at the conclusion of the regular gynecolog-
ical examination and on the regular gyne-
cological table. The inflation is preceded by
an injection of Schleich's solution and the
point selected for puncture is usually about
one inch below the umbilicus in the median
line, unless previous operative scars, evi-
dence of adhesions, or other pathology, con-
tra-indicate.

Carbon dioxide is taken from one of the
usual commercial tanks from which a nitrous
oxide bag is filled, and this bag is then con-
nected with the needle without intervening
manometers or washing or sterilizing ap-
paratus. During inflation, the bag is held be-
tween the knees of an assistant, thereby giv-
ing complete control over the pressure as
well as giving a fair indication of the
amount of gas which has been injected. We
have found that from ij4 to 2 liters of gas
are sufficient to produce a- fair inflation of
the pelvis, although in certain individuals
the bowel coils can still be seen resting on
the anterior abdominal wall in the most de-
pendent portion of the belly.

The patient is then turned over on the
face, being held in the knee-chest position
until an inclined board can be placed beneath
the thighs. This board makes an angle of
about 28 degrees with the plane of the table
and its upper portion is cut out and rounded
so that the pubis comes to lie just about the
deepest portion of the notch. An 18 inch
square of opaque fabric with a 6^ inch
circular hole cut out of its center is laid on

"Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn., Sept. 14-17, 1920.

Pneumoperitoneum of the Pelvis

the buttocks and serves as a diaghragm. A
plate changing tunnel is then placed horizon-
tally on the table, double screen films are
used, and a Coolidge portable unit, operating
on the ordinary lamp circuit, furnishes the
;r-ray. An exposure of from fourteen to
twenty seconds is required, and ordinarily
each exposure is interrupted, being made at
such intervals as the breath can be held con-
veniently, and the patient allowed to breath
between the fractional exposures.

The tube shift is in the long axis of the
body and the stereo set so produced is used
as though the patient were lying on the right
side.

This technique is the result of a series of
progressive improvements. For instance, at
first we used oxygen and brought the pa-
tients down to the .r-ray room where they
were first "screened" and then "plated."
This method was entirely satisfactory from
the .r-ray point of view, but there was con-
siderable complaint on the part of the patient
for twenty- four or forty-eight hours if they
attempted to move from the rigidly dorsal
decubitus. Consequently a similar procedure
was attempted with carbon dioxide; but it
was found that if there were any unusual de-
lay in the transportation of the patient —
over several floors and down at least two
elevators — the amount of gas remaining in
the peritoneal cavity was insufficient to se-
cure satisfactory plates. The portable .r-ray
machine used in the gynecological examin-
ing room seems to be a perfectly satisfactory
solution of this difficulty.

We have also found that not so large an
amount of gas is necessary for the inflation
of the pelvis as for a satisfactory examina-
tion of the abdomen as a whole. Provided
the examination can be undertaken immedi-
ately, we now believe that from a liter to a
liter and a half is sufficient to inflate a pelvis
of ordinary size. However, in order to be
certain that all the intestines which normally
lie in the pelvis may have a chance to escape,
we prefer to give two liters of gas wherever
the patient does not complain too seriously.

In the earlier cases there was considerable

complaint, on the part of the patients, of
persistence of the pain and discomfort for
twenty- four to forty-eight hours. Accord-
ingly, deflation was practiced. Since the in-
troduction of carbon dioxide, deflation has
not been necessary, and patients inflated at
about 1 1 o'clock in the morning have taken
their noonday meal in the sitting posture
with complete comfort and no more reports
of sleepless nights have been encountered.
This is undoubtedly due to two factors: first,
the more rapid absorption of carbon diox-
ide; and, second, to the smaller quantity of
the gas introduced in the later cases. While
discomfort and a sense of oppression are a
constant complaint, these are not important
except in cases with serious pathology in the
upper abdomen or (as we suspect) with
adhesions to the parietal peritoneum in the
abdomen or pelvis.

For a time we introduced a short narrow
helix of wire into the vagina for the purpose
of simplifying the recognition of the various
shadows in the pelvis by reason of the better
differentiation which would result from a
demonstration of the axis of this cavity. The
shadow of the fundus of the uterus which
in the earlier experiments was apt to be hid-
den in the shadow of the bladder, was
thereby thrown backwards and more nearly
into the axis of the pelvis and was more
clearly outlined. However, because of the
distortion which was introduced by the in-
flation of the vagina and the bulging of the
posterior vaginal wall into the cul-de-sac of
Douglas — almost invariably to one side of
the median line — and because of the result-
ing distortion of the position of the uterus,
this procedure has been discontinued.

It is probably superfluous to speak here of
the advantages of the stereo set. However it
is well to realize that the stereo effect in
pelxis A--rays is not nearly so perfect as it is
in the study of the bones or of the chest. The
appreciation of depth is only possible when a
definite point or a series of points is pre-
sented to the eye, establishing a definite par-
allax. In the case of a smoothly rounded soft
tissue bodv of uniform densitv, such as we

Pneumoperitoneum of the Pelvis

are dealing with in the pelvis, such points are
not normally found. The only lines upon
which the eye can fix are the shadows of
those portions of the perimeters of such
bodies which are projected by rays which
are tangent to the surface at these points.
The depth of the fundus of the uterus
appears, therefore, to lie in the position of its
equator, and one gets no impression of the
extent or the position of that organ above or

the diffuse shadows of the abdomen. Our
appreciation of the contour of this body is
accordingly somewhat fragmentary and our
conception of its shape may be quite erro-
neous. Nevertheless we believe the stereo set
to be well worth while because of the ease
with which the rather complex shadows of
the pelvis ma}- be resolved, the extraneous
shadows excluded, and the relative position
of these cross sections appreciated.

Fig. I. Normal Pelvis. Note the optical cross sections of the isthmus and fundus

of the uterus.

below that point. The image of an irregular
body will be represented by a series of "op-
tical cross sections" at the point of tangency
of the projecting rays. For instance, the im-
age of the uterus, four months pregnant, is
represented only by the cross section of its
enlarged cervical or supracervical portion
(the isthmus) and by the shadow of the an-
terior surface of the neck just behind the
pubis where it curves upward and extends
into the abdominal cavity, while the upper
margin of the body of the uterus is lost in

Our experience is obviously too limited to
give an exhaustive exposition of the signifi-
cance of the shadows seen. We have, how-
ever, tentatively reached certain conclusions
which may be of value in the further study
of this branch of roentgenographic work.

It appears that the normal pelvis is rather
easily and regularly freed of all intestinal
coils with the exception of that portion of
the pelvic colon and the rectum which have
no mesentery ; and that this may be accom-
plished with a comparatively small amount

Pneumoperitoneum of the Pelvis

of gas. The shadow of the rectum is closely
applied to the anterior surface of the sacrum,
and as it is projected well above the shadows
of the female generative system, it offers no
confusion if the technique advocated is fol-
low^ed. It makes little or no difference
whether it be full or empty. Even barium-
containing feces serve only to fix the position
or facilitate the orientation of the im?ge.

cient. that conclusion seems to be justified by
our experiences.

If a perfect degree of elevation of the hips
has been attained and the direction of the
ray is in the long axis of the pelvis, both the
anterior and posterior pelvic pouches are
empty of everything but gas. In the presence
of pathology, either the one or the other may
be filled with inflammatorv exudate or ad-

FiG. 2. Pregnancy at Six Weeks. Mass on the left, possibly the ovary,
with corpus luteum vera.

Whether this rule of the mobility of the
pelvic intestinal coils is so invariable as to
justify the conclusion that the presence of
such shadows is an evidence of pathological
adhesions, remains in doubt and obviously
will always remain dependent upon the care
exercised in the details of the technique and,
in particular, upon the quantity of the gas
injected. With the exception of a few cases
in which the inflation obviouslv was insuffi-

hesions, or incarcerated bowels and omen-
tum, with consecutive displacement of the
uterus and the broad ligaments which form
the transverse partitions of this portion of
the pelvis. Such displacement with oblitera-
tion of either of the pouches is one of the
most striking features of inflammatory dis-
ease of the pelvis.

When entirely empty, the bladder shadow
is scarcelv recognized on the posterior sur-

Pneumoperitoneum of the Pelvis

face of the pubic bone. When distended,
however, it may be seen as a rounded
shadow of no very great saHency exactly
where one would expect to find it, and its rec-
ognition is never a matter of great doubt.

The fundus of the uterus in a properly
placed patient is separated from the bladder
shadow by the space of the anterior or utero-
vesical pouch which normally contains gas.

ever, that the same result may be accom-
plished by a slightly greater elevation of the
hips and a little more care in directing the
ray.

On either side of the uterine shadows are
seen the narrow linear shadows of the broad
ligaments clearly spreading out at either
end, centrally embracing the uterine shadow
and peripherally fusing with the pelvic wall.

Fig. 3. Unilateral Disease of the Tube. At Operation Contained Pus.

In the presence of a marked relaxation of
the pelvic floor, or where the position is not
satisfactory, it may be found to lie on the
posterior surface of the bladder and may be
exceedingly difficult to recognize. This is
particularly true in cases of senile atrophy.
The introduction of a helix of wire into the
vagina with the resulting dilatation of this
cavity seems to help to throw this shadow
backwards, more nearly into the axis of the
pelvis. Our experience appears to show, how-

Wherc the uterus is displaced or distorted,
these broad ligament shadows serve to di-
rect one to the position of this organ. It ap-
pears that they are best seen at a level some-
what above that of the cervix, but well be-
low the equator of the fundus.

We have never, to our knowledge, recog-
nized the round ligaments and greatlv ques-
tion whether they would ever appear on the
plate. We have once or twice imagined we
could see them, but operation proved that

Pneumoperitoneum of the Pelvis

they lay in quite a different position. Care-
ful examination of the opened pelvis gives us
no reason to suppose that these exceedingly
tenuous structures with their thin enveloping
layers of peritoneum could reasonablv be
expected to show in the relatively large mass
of tissues which the ordinary female pelvis
presents.

The normal tubes are not seen as a separ-
ate or recognizable shadow. They apparentlv
are component parts of the broad I'gament

and encroached upon by what appears to be
inflammatory tissue and cicatrix.

The normal ovaries apparently are not
seen. They probably lie on the postero-lat-
eral aspect of the uterus slightly below the
e(|uator so that they form an integral part
of the uterine shadow. Their position is ex-
ceedingly difficult to verify from the fact
that the operation is invariably undertaken
in the Trendelenburg position, while the
roentgenogram is made in precisely the re-

FiG. 4. Bilateral Tibal and Ovarian Diseask.

shadows. When distended or inflamed, how-
ever, they become conspicuous as tortuous
shadows on the posterior surface of f^e
broad ligament shadows, possibly obliterat-
ing them by overriding, or as pear-shaped
shadows in the postero-lateral portions of
the pelvis. In chronic cases the picture may
be much confused by the overlying (adher-
ent?) intestinal coils. The distortion pro-
duced may make it difficult to recognize the
shadow of the uterus and almost invariabh'
the posterior cul-de-sac is much contracted

verse, namely, the knee-chest position, and
the effect of gravity would be to carry the
ovaries upward rather than downward and
backward. A curious observation is that the
ovarian shadows are very conspicuous and
easily recognized in cases of retroversion and
"prolapse of the appendages," evidently be-
ing carried backward by the pathological
shortening of the utero-ovarian ligaments. It
is also worthy of note that a refractory re-
troverted uterus which cannot be replaced by
ordinarv manipulation appears to effect a

Pneumoperitoneum of the Pelvis

spontaneous reduction and is represented by
an enlarged fundus almost in the axis of the
pelvis and flanked on either side and pos-
teriorly by the conspicuous ovaries closely
applied to its postero-lateral aspect.

Ovaries containing small cysts have been
found and recognized as ovaries although
the cystic element was not recognized.
Larger ovarian cysts produce a variable pic-
ture that will leave one rarely in doubt. Con-
siderable distortion may result, as in the
specific case of a young girl with a pendulous
cystic ovarA' which hung apparently almost

the direction of its axis; but pathology in
this neighborhood, such as carcinoma of the
cervix, may be expected to escape detection
entirely except in so far as it encroaches
upon the structures above the deepest por-
tions of the cul-de-sac.

Enlargements and tumors of the pelvic or-
gans cast conspicuous shadows and often
rise into the abdomen. We are not yet ready
to formulate any comprehensive set of rules
for their differentiation, because of the pau-
city of our data. We tentatively offer the
observation that the pregnant uterus casts

Fig. 5. Chronic Pelvic Inflammation. Note the oI)litcratioii l)y adhesions of the
posterior cul-de-sac and the distortion of the broad ligaments.

in the exact axis of the uterus so that the
differentiation of its shadow was impos-
sible in the imperfect state of our knowledge
at that time. The unusual mobility of this
cystic ovarv was clearly demonstrated at
operation.

The cervix and the vagina, as well as all
structures in the pelvic floor which lie below
the level of the peritoneal pouches behind the
broad ligament, are entirely undifferentiated,
and it is entirely probable that considerable
infiltration of the soft tissues in this neigh-
borhood will leave no recognizable evidence.
The insertion of a helix into the vagina
serves to fix the position of this cavity and

a shadow less dense than myomata. One gets
the impression of a high degree of elasticity,
and the enlargement of the isthmus, or
supracervical portion, of the uterus as seen
in cross section, as well as the broadening of
the broad ligaments, is more conspicuous in
pregnancv than with tumors. Incidentally the
shadow of the fundus of the uterus is not
differentiated once it is out of the true pelvis,
akhough its anterior surface at the plane of
its inflection can sometimes be seen imme-
diately behind the pubic bone. In fibroid of
the uterus, on the other hand, the cross sec-
tion of the isthnuis is not enlarged, the mass
has considerably greater density, and does

Pneumoperitoneum of the Pelvis

not appear to be flattened out as in the case
of the pregnant uterus.

It would be an obvious error to attach any
great weight or authority to the above hasty
generalizations on so few observed cases. We
have found that a diagnosis is anything but
easy, and continue to meet with a discourag-
ing number of disappointments. The find-
ings, however, are so striking and the stereo-
scopic picture so intriguing that we cannot
refuse to entertain the hope that reliable cri-
teria of interpretation will be developed by
a continuation of these studies. Both Dr.
Peterson and myself are planning later com-
munications on the results of this work as
soon as reliable conclusions seem justified.

Even though the method can be developed
to the point where a reliable judgment is
possible on the part of the roentgenologist.

it is not at all certain that his opinion will be
of material diagnostic assistance to the
gynecologist, since he, the gynecologist, is
already fairly competent to reach a satisfac-
tory conclusion by bimanual palpation.
However, several instances in which inter-
esting, if not essential, information was ob-
tained, seem to warrant the expectation that
the method will find a legitimate application
in selected cases and furnish a common inter-
est with still another specialized branch of
modern surgery with which we, as roent-
genologists, have heretofore found few
points of contact.

[Note. The discussion of this and other pa-
pers relating to Artificial Pneumoperitoneum
presented at the Twenty-first Annual Meeting
will follow the publication of the entire series.]

THE TREATMENT OF CARCINOMA OF THE BREAST BY
IMBEDDING RADIUM SUPPLEMENTED BY X'RAY^=

By RUSSELL H. BOGGS, M.D.

Roentgenologist, Allegheny General Hospital; Dermatologist and Roentgenologist, Columbia and

Pittsburgh Hospitals

PITTSBURGH, PEXNSYLVANIA

divergence of the rays, and practically noth-
ing was known about the lethal dose of dif-
ferent types of malignant cells. Most radiol-
ogists compared everything with the amount
of radiant energy necessary to destroy ro-
dent ulcer; and when the squamous cell
epithelioma, axillary nodes and a cancerous
mass in the breast did not disappear under
.r-ray, the radiation was considered useless.
The real fact was that a lethal dose had not
been given.

Radiation for the treatment of carcinoma
of the breast has been so changed by imbed-
ding radium that where only superficial skin
effects were formerly produced, now cancer-
ous tissue deeper than that which can be
removed by the knife can be destroyed with-
out opening the lymphatic chains. Before im-
bedding radium 1 always give surface ap-
plications in the axilla and over the glands
below the clavicle, and I give a complete
course of heavy filtered .r-ray treatment to
the breast and all the glands draining it. This
checks cell proliferation and lessens the dan-
ger of metastases when the breast and ad-
jacent lymphatics are speared and radium
inserted. It is generally agreed that it re-
quires from two to four weeks to check cell
proliferation. It has been shown that the
lymphatics begin to undergo a fibrosis at the
end of the fourth week and that the caliber
of the lymphatic vessels are smaller than be-
fore treatment was given. It seems just as
advisable to give surface treatment before
imbedding radium as before operation. Some
few surgeons are now advising ante-opera-
tive treatment, and if they would include
imbedding radium and remove less tissue,
thereby leaving the sclerosed lymphatic tis-
sue as a barrier against cancer cells, I feel

"Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn., Sept. 1-1-17, 1920.

T N all the progress made in recent years in
-*- radiotherapy, nothing has been evolved
of such significant import in the treatment
of carcinoma of the breast, as the advanced
method of imbedding radium, with its mani- '
fold and varied advantages and possibilities
in deep therapy. By imbedding radium
throughout the entire breast, in the axilla,
into the glands leading from the breast to
the axilla and into the glands below the
clavicle, it is now possible to make radiation
for carcinoma of the breast as thorough as a
radical dissection without opening the lymph
channels. Supplementing Coolidge .r-ray
treatment to the twenty or more lymphatic
chains draining the breast, using lo mm. of
aluminum and cross-firing as much as pos-
sible, there is completed the most advanced
and most effective treatment, which is in
marked contrast to the treatnient given fif-
teen or twenty years ago with a compara-
tively low penetrating gas tube, using no fil-
tration or meters for giving exact dosage,
and thus administering only superficial ra-
diation when deep treatment was necessary.
In the early days of radiotherapy a deep
lethal dose could not be given without pro-
ducing superficial ulceration or necrosis. By
imbedding radium a lethal dose can be given
without any effect on the skin. Besides the
subcutaneous tissue will tolerate from three
to five times as much radiation as the skin.
The result of radium in malignancy depends
upon whether a lethal dose is given. For-
merly it was concluded, because our best
radiograms were taken with comparatively
low tubes, that this form of radiant energy
was the most suitable for deep therapy.
Almost every one overlooked the loss of
energy by absorption in the tissues and by

Radium and A'-Rav Treatment of Carcinoma of the Breast

sure that the end results would be better, at
least in borderline cases ; that is, there would
be fewer recurrences, and if a recurrence did
take place it would be considerably later than
when the operation precedes radiation.

Imbedding radium in the treatment of car-
cinoma of the breast is a step in advance, but
the number of cases treated by this method
are not sufficient and its use is of too short
duration to speak about anything but tem-
porary results. Even in some of the ad-
vanced cases the disease in the breast and the
glands appears to have retrogressed, clini-
callv. Of course in some cases there is still
thickening due to the fibrosis from the radia-
tion. Not enough cases have been oper-
ated upon to give definite histological
changes. In the inoperable cases we were in-
clined to leave well enough alone, and in
the early cases each one has refused opera-
tion. ]\Iv advice has been, even in the ad-
vanced cases, where the disease has clinically
receded, to have the breast removed with-
out opening the axilla ; but to my extreme
disappointment, in almost every advanced
case that I turned over to the surgeon he
opened the axilla, and when the patient re-
turned, almost without exception she had a
swollen arm and was in much worse condi-
tion than before operation. I feel sure, how-
ever, that if we could have the surgeon re-
move only the breast, thereby taking away
the unhealthy mammary gland, the patient
would be greatly benefited. I am speaking of
the advanced or inoperable cases which have
had thorough radiation, and not the early
cases which we are advising to have ante-
operative radiation. Imbedding radium as
described takes the place of operation in ad-
vanced cases, and as before stated, the re-
moval of the breast is all that is advised.

It is imperative that every therapeutist
should make a comprehensive study of the
lymphatics draining the breast before he at-
tempts to treat mammary carcinoma. The
lymphatic supply to the breast is greater than
to almost any other organ of the body. A
study of the lymphatic and bone metastases
will show that although the case is operated

on early, the raying of the line of incision,
axilla and supraclavicular region is very in-
complete.

Deaver's classification in regard to end
results are probably as near correct as that
of any other author and should be studied
by the surgeon and radiotherapeutist. He
says: "It has been stated that 80 per cent
of patients in whom the disease is confined
to the breast, as proved by both microscopic
and macroscopic examination of the tissues
adjacent to this organ, are permanently
cured of their disease by the radical opera-
tion. Therefore, a patient presenting a small
movable mass localized in the breast can be
assured that four out of five cases of a simi-
lar nature are cured by operation. When
axillary lymph nodes are palpably enlarged
as the result of metastases, the chances of
operative cure are at once diminished to one
in five."

This deduction is practically the same as
that of Halstead, who says that, notwith-
standing the present day extensive operation,
death from metastases occurred in 23.4 per
cent, even in cases with a microscopic nega-
tive axilla. Deaver cjuestions whether as
much palliation is received from operative
as from non-operative methods, and ex-
presses his general dissatisfaction with oper-
ation of a palliative nature in the treatment
of carcinoma of the breast, since in certain
cases the disease has been excited to greater
activity by an incomplete operation, and the
life of the patient considerably shortened.

In this connection he mentions the unre-
served statement of Bloodgood, "that incom-
plete operation hastens death."

The above quotation which is taken from
Deaver's carefully prepared volume, "The
Breast, its Anomalies, its Diseases and their
Treatment," should receive more attention
from the medical profession.

The prognosis and treatment of mammary
carcinoma can be estimated only after con-
sideration of many factors. Hanley consid-
ers operation contra-indicated when there is
extensive ulceration and when the tumor is
adherent to the chest wall ; when axillary

2.2

Radium and A'-Ray Treatment of Carcinoma of the Breast

nodes are flexed ; when there is supraclavicu-
lar involvement and when there is indication
of distant metastases. When the axillary
glands are palpable there are very few cures
by surgery alone without radiation, even
when the axillary nodes are not palpable ;
and when the glands are found to contain
cancer cells microscopically only about 20
per cent of the cases are cured at the end of
five years. Greenough claims that when the
axillary nodes are palpable, 12 per cent were
cured by operation, and Finsterer stated 4.3
per cent. Ewing believes the latter represents
the average success by surgery, which means
that a woman who has a well established
cancer of the breast, with palpable axillary
nodes, has one chance in twenty-five of be-
ing cured bv operation. Therefore, in cases
of this class it is not too much to advise im-
bedding radium and giving a thorough
course of radiation before the removal of
the breast.

The clinical and pathological studies of
cancer of the breast have shown that both
surgery and radiotherapy meet with many
difficulties and uncertainties. The anatomical
types are so many, the variations of the
clinical course are so wide, the paths of dis-
semination so diverse and the difficulty of
determining the actual condition so complex,
that giving a lethal dosage is difficult. Since
Deaver and Bloodgood both claim that an
incomplete operation hastens death, there is
good reason for advocating the imbedding
of radium into the breast and into the adja-
cent lymphatics wherever possible. A study
of autopsies shows that almost any organ of
the body may metastasize from cancer of
the breast, and however closely confined to
the superficial tissues the growth seems to
be, no one can tell where the cancer-grown ng
edge may extend ; although unappreciable
by ordinary methods of examination, it is
just as definite as ringworm. This shows us
that even in the early cases no lymphatic
chain should be omitted when raying the lym-
phatics with a Coolidge A'-ray tube, and as
much cross-firing should be used as possible.
In an article which I read before this societv

in 1 91 7, I described the glandular distribu-
tion of the breast and the method of raying
with a Coolidge A'-ray tube. Since then I
have been using 10 mm. of aluminum, giving
from fifteen to twenty minutes' exposure. At
that time I made the statement that "we are
all looking for some means by which the
skin will tolerate larger doses." This has to
a certain degree been accomplished by im-
bedding radium and using heavier filtered
A--rays.

After cancer cells have reached the axil-
lary nodes, the disease soon becomes gener-
alized, and tissue in almost any part of the
body may become involved. If we had an
A'-ray microscope and it were possible to give
a lethal dose to all cancer cells, the end re-
sult would be different. When it is impossible
to give a lethal dose, palliation and prolonga-
tion of life is obtained in nearly all cases.
Less than a lethal dose will usually stop cell
proliferation, produce a fibrosis of the lym-
pliatics and obstruct or obliterate the lym-
pliatic vessels, thereby checking cancer dis-
semination. In fact, radiation changes the
character of the disease, transforming it into
more of a scirrhus form, by decreasing glan-
dular cells and increasing the fibrous stroma.
This mechanical choking clinically seems to
influence the constitutional resistance of a
patient. The same difficulty is not encoun-
tered in giving a lethal dose when radium is
imbedded in cancerous tissue as when deep
seated metastases are treated either by sur-
face applications of radium or .I'-ray.

In calculating the filtration and the num-
ber of ports of entry or the amount of cross-
firing necessary to give a lethal dose to met-
astatic lymphatic glands, it is necessary not
only to know the anatomical situation, but
we must know the depth and density of the
overlying structures. It makes cjuite a dif-
ference whether the glands are situated one-
half inch or four inches from the surface.
The erythema dose in carcinoma of the
breast is very seldom the lethal dose. The
lethal dose is from three to six times the
amount of the erythema dose. Therefore, if
a surface ervthema dose is given and the

Radium and A'-Ray Treatment of Carcinoma of the Breast

disease is four inches below the surface of
the skin, the loss of radiant energy by di-
vergence of the rays and absorption of the
tissues with an ,r-ray tube placed eight inches
from the surface with the equation used, is
about one-ninth; or in other words, only
about one-ninth of the surface radiation
reaches four inches below the surface of the
skin. Then if the lethal dose is from three to
six times the erythema dose, it can be readily
seen that when only one port of entry is
used the treatment would be useless. For-
merly, too many were satisfied with the re-
moval of the visible part of the disease. The
degree of malignancy is no guide to the
amount of radiation determining its lethal
dose. On account of rodent ulcer growing
slowly and responding to small amounts of
radiation, these circumstances led many to
believe that a lethal dose was determined by
the degree of malignanc}^ of a tumor. Medul-
lary carcinoma may respond more readily
to radiation than the scirrhus type, but it
grows more rapidly and invades the glands
early, so if a cure or even an inhibitory ef-
fect of the disease of this type takes place,
both the local tumor and metastases must be
given sufficient radiation. If results are going
to be produced in the medullarv type, the
cancer cells must show effect within three
or four weeks, and fibrous tissue must be
forming at the end of this time. In the scir-
rhus type, the fibroid formation has already
taken place by nature's process.

When we speak of the lethal dose of ra-
diation, we refer to direct action on malig-
nant tissue; but there is an indirect effect of
radiation on malignant cells by the forma-
tion of fibrosis which starts to form three or
four weeks later. Both are important, and a
lethal dose should be given whenever pos-
sible, but less than a lethal dose sickens the
malignant tissue, as Mayo expresses it, and
starts the formation of fibrous tissue which
is a barrier against the disease. In locations
where radium can be buried a lethal dose can
nearly always be given, but in the treatment
of deep metastatic glands we may be com-
pelled to depend upon both the direct and

indirect effect of radiation on malignant
cells. Therefore, when carcinoma of the
breast is so far advanced that a cure cannot
be expected, the patient should have all the
palliation possible from both the direct and
indirect effects of radium and ;ir-ray.

In a tumor that does not respond readily
to radiation there is more necrosis and less
absorption when a lethal dose is given. In
two cases in which the mass in the breast
was hard and of long duration, the growth
was walled off, and when the breast was
speared, broken-down non-offensive material
came out through the trocar. This was due
to heavy surface applications of radium. In
each of these cases a clinical cure was ob-
tained after imbedding radium, and the nor-
mal tissue was not injured in either case.

The ability to classify cases requires clini-
cal experience and forms an important part
of the training of the radiologist. The ques-
tion of large dosage altering normal tissue
after the reaction has disappeared is an im-
portant factor, and this alteration of tissues
will not permit the normal tissue to bear so
well a second, third or fourth exposure. The
normal tissues are usually injured by a fre-
quent repetition of the radiation, while the
cancerous tissue, if any remains, may not
retrogress in a proportional degree. In fact,
the cancer cell and normal tissue may react
in about the same degree, or there may be a
reversal of the primary susceptibility. This
shows the advantage of imbedding radium
wherever possible after a maximum surface
dosage has been given.

The method I have adopted is to give a
thorough course of Coolidge ,r-ray treatment
to all the glands draining the breast, using
the following equation". 10 mm. aluminum,
8 inch tube distance, five milliamperes of
current, nine inch spark-gap and from fifteen
to twenty minutes' exposure. A constant
voltage is difficult to obtain. The pastille ery-
thema dose is very unreliable and is not as
accurate as the milliampere dose, using the
different types of transformers with a fluctu-
ating voltage. Calculations based upon false
assumptions have been very misleading, and

Dislocation of the Carpal Scaphoid

in giving a lethal dose exact standards must
be employed. In many of the cases the breast
and axilla receive a maximum dose from ra-
dium packs before imbedding radivun.

Two or four weeks after surface applica-
tions I have been imbedding lo mg. radium
needles (vanadium steel needles, thickness
of wall .35), placing them i cm. apart,
and giving from five to eight hours' expo-
sure. In some cases this produced a slight
inflammatory reaction, but in no case has
necrosis taken place. I may say that I started

over three years ago — most reluctantly — to ■
imbed radium in more superficial lesions; I
can now indorse this technique as presenting
many points of advantage over surface ap-
plication in the treatment of many forms of
malignant lesions, but it will not take the
place of the Coolidge .^--ray tube in the treat-
ment of distant and deep metastases.

[Note. The discussion of this and other pa-
pers relating to Therapy presented at the
Twenty-first Annual Meeting will follow the
publication of the entire series.]

DISLOCATION OF THE CARPAL SCAPHOID

By T. S. BONNEY, D.D.S

ABERDEEN, SOUTH DAKOTA

np HERE is very little to be found in the
-*■ literature relative to dislocations of
the carpal bones except that the condition is
very rare; and the following case seems
worthy of report for that reason. I was priv-
ileged to make the .r-ray plates of this case
through the courtesy of Dr. C. E. McCauley
of this citv.

Mr. L. J., age twenty-one, suffered a fall
from a horse on October 15th, striking on
his right hand, and was seen by Dr.
McCauley October 17th, at which time the
-I'-ray examination of the wrist was made by
myself.

The accompanying cuts show clearly the
dislocation of the bone in cjuestion.

Fig. I. Showing Dislocation of the Right Carpal Scaphoid.

X-RAY TREATMENT OF TONSILS AND ADENOIDS

By W. D. WITHERBEE, M.D.
Radiotherapist, Presbyterian Hospital

NEW YORK CITY

"POLLOWING the suggestion of Dr. J. B.
-■- Murphy/ I treated the first case of hy-
pertrophied tonsils in December, 191 9, at the
Rockefeller Institute for Medical Research.

This case, although carefully examined,
revealed no changes in the surface size or
outline of the tonsil, until the fifth week fol-
lowing treatment. The first evidence of the
effect of A"-ray was a smoothing out of the
tonsillar mucous membrane, which very soon
resulted in a glazed and somewhat pale
surface.

This was followed by a rather rapid de-
crease in size, which in this case was most
apparent in the left tonsil. At the end of
eight weeks the left tonsil was seemingly
reduced one half and the right one third.

About this time a dose similar to the first
was given. Since then and up to the present
time this patient has had no further trouble
and the tonsils are apparently now both
about one fourth the original size.

As soon as the effects on this case became
conclusive Dr. S. L. Craig and I started a
series of cases which numbered in all about
sixty and ranged in age from sixteen months
to fifty years.

In this series every patient was required to
report for examination weekly. The history
of each case was taken, a blood count made,
the contents of the crypts plated and col-
onies of bacteria counted. A drawing of the
throat and tonsils was made and notes were
taken each time in regard to the progress of
the case. Very few of these cases received
more than one treatment, as we wished to
determine the time necessary for the .I'-ray
effects on the tonsil, and thus decide on the
number of treatments required in a given
case.

The amount of .r-ray used in the experi-
mental series of sixty cases varied from
three to seven minutes time, depending on

the age of the patient, with an 8 inch spark-
gap, 5 milliamperes and 10 inches distance,
filtered through 3 mm. of aluminum. This
dose of filtered ;r-ray is less than the stand-
ard amount used for the past twenty years
in the treatment of ringworm of the scalp in
children, which fact overcomes the possible
objection of any untoward effects on adja-
cent tissues from the standpoint both of
amount, and of area of the head exposed.

In ringworm of the scalp five exposures
are necessary in order to obtain uniform re-
sults of epilation. Only two exposures are
necessary in each treatment of tonsils, and
the maximum dose used is i ^ skin units ^ of
filtered ray, which corresponds to less than
I skin unit used in temporary epilation of
the scalp in children. It is generally con-
ceded by most writers on this subject that
the increased size of the tonsil depends di-
rectly upon the increase of the lymphatic
tissue. The follicles appear larger than nor-
mal, are less sharply outlined, and usually
the germinal centers are quite prominent and
contain numerous mitotic figures. Occasion-
ally the lymphoid cells appear to overflow
into the interfollicular structures. According
to Kelhrt ^ the hypertrophy of the follicles
appears to cause distortion of the crypts,
thus aiding in retention of the crypt contents.

The effect of .r-ray on lymphoid tissue in
the diseased tonsil is exemplified in the dia-
grammatic representation Figure i. The de-
structive action of A'-ray on the cells of the
Ivmph follicles of both the lymphoid and
fibroid tonsil are also well outlined.

The sections taken from an enlarged ton-
sil (Fig. 2) and the two made of tonsils
enucleated eight weeks and four months af-
ter one massive dose of .r-ray (Fig. 4) indi-
cate the cause of the shrinkage of the tonsil
and expulsion of crypt contents.

The selective action of x-rnxs on embry-

A'- Ray Treatment of Tonsils and Adenoids

onic tissue or its effect on the cell in certain
phases of mitosis are the usual methods of
describing ;r-ray effects on diseased cells as
compared with normal cells.

V B © ^e'-* ^/<9->.r& j?f^-

^/i

ft© ^)tyW"''-r,
•s"- i; (J t-'

-TV

Fig. I. I. Standard Lymph Follicle, ii. Lymphoid
Hypertrophy, iii. Fibrous Hypertrophy, iv. Effects
of X-Ray on Lymph Follicles.

The destructive action of .I'-rays on the
cells of these enlarged lymph follicles might
also be explained on the ground of their hav-
ing been stimulated to excessive cell prolif-
eration to such an extent that there remains
less resistance to the .t"-ray than in the nor-
mal cell. Therefore this difference in resist-
ance would account for the small dose of
jr-ray necessary to destroy these pathogenic
lymph follicles without interfering in any
way with the normal adjacent cells.

The bacteriological report embodied in the
following table indicates the possibilities of
the bacterial cryptic contents after one mas-
sive dose of .r-ray. This case and a few
others examined three months after .r-ray
treatment, showed negative cultures for
pathogenic bacteria. The results in all cases
were not as clean-cut as in this case. This
might be explained by the fact that in passing
the platinum loop into the crypt no method
has as yet been devised whereby the surface
of the tonsil can be rendered sterile in order

TABLE I

March 3, ig20
Right Tonsil, 24 hrs., 50 Colonies of Hemo. Strep.

Staph.
Strep.

Staph.

March 17, ig20 — 2ud Week Ajtcr X-Rays

Right Tonsil, 24 hrs., Xo Colonies of Homo. Strep.

" " 24 " " '■ " " Strep.

No " " " Staph.

Left Tonsil 24 " " " " " Strep.

" " 48 " " " " " Strep.

No " " " Staph.

Vault, 24 " No " ' " Strep.

48 " " " " " Strep.

No " " " Staph.

48 "

100

Left Tonsil

-24 "

48 "

\'ault

•24 "

48 "

50
150

.- ..j-i.

Fig. 2.

Fig. 3.

A'-Rav Treatment of Tonsils and Adenoids

to avoid contamination from the mucous
membrane. However, this can readily be ac-
complished with enucleated tonsils by dip-
ping them for one minute in boiling water.
Thirtv-two out of thirty-six cases showed
negative cultures for pathogenic bacteria
four weeks after one massive dose of .r-ray.
Figure 5 illustrates the diminution in size
and characteristic changes in the surface of

sil as shown in Figure 7 but also include the
right tonsil and adenoids as the rays pass on
through the opposite side of the head and
neck.

This position can be assumed b)- the adult
patient with the proper placing of pillows or
cushions without the use of restraining
straps and board so essential in the treatment
of young children.

3porrs

2 weeks later

¥\i,. 4.

the tonsil at various periods of time after
one massive dose of .r-ray.

.r-RAY TECHNIQUE

Figures 6 and 7. illustrating the position
and immobilization of the younger patients
give a much better idea of the practical ap-
plication of the .r-ray than the most accur-
ate description. Figure 6 represents a board
4 feet long, 10 inches wide and i inch thick
over all. The longest piece for the support
of the body is 3 feet. The head piece is i foot
by 10 inches and i inch thick with a bevelled
opening 2^ inches in diameter. This open-
ing prevents undue pressure and discomfort
of the ear. The distance from the table level
to the apex of the angle made by the union
of the head piece and body support is 33^
inches. This angle and inclining head board
not only give the position necessary for the
direct exposure of the adenoids and left ton-

:r ■ 8 v/eeks later

Fig. 5.

Bv maintaining the above position and
placing the .r-ray tube at the proper angle in
both children and adults it is evident that
each tonsil and the adenoids receive two
doses of .r-ray.

The opening in the lead foil, as in Figure
7, should be not less than 3 inches by 2^/2
inches for the average case. Figure 8 repre-
sents the area of exposure, and illu.strates
the area and position of the patient when a
third exposure is considered necessary for
cases with extensive growth of adenoids.

DOSAGE

In the experimental series of si.xty cases
treated at the Institute the following factors
were used with 3 mm. of aluminum: 8 in.
Sp. Gap. 5 M A 10 in. D and from 3 to 7
minutes time for each exposure depending
on the age of the patient.

From the experience with these cases and

A'-Ray Treatment of Tonsils and Adenoids

DANGERS OF FAULTY TECHNIQUE

subsequent treatment of other cases, frac-
tional dosage seems to promise better and
more uniform results than the single massive Before leaving the subject of dosage it is
dose used in the above series. necessary to point out clearly that anyone

Fig. 6.

Fig. 7.

It therefore seems advisable to give each
case at least four treatments as a minimum
using the following factors every two weeks:
7 in. Sp. Gap. 5 M A 10 in. D and 3 min. 18
sec. time through 3 mm. of aluminum. These
factors give i skin unit of filtered rav, which

Fig. 8.

corresponds to Yz skin unit unfiltered in ef-
fect on the skin. The same result may be
obtained by producing i skin unit of filtered
ray with a 6, 8 or 9 inch spark gap ^ 5 M A
10 in. D with 3 mm. of aluminum, or if nec-
essary I mm. of aluminum could be used in-
stread of 3 mm. to save time, especially with
the small (2 K W) interrupterless machines
where a 6 inch gap is maximum. The factors
for I skin unit with i mm. of aluminum
would be 6 in. Sp. Gap 5 M A 10 in. D and 2
min. 41 sec. time.^

The next best method would be two or
three massive doses given with four to six
weeks intervals.

contemplating carrying out this technique
who does not thoroughly understand the part
played by each of the four factors of dosage
and who has not mastered his machine and
tube so that all four factors are constantly
maintained throughout the exposure will
sooner or later produce an .t'-ray burn with
its consequent permanent deformity and ten-
dency to epitheliomatous degeneration. The
only contra-indications to the immediate use
of .r-ray are: recent radiographs of the re-
gion to be exposed ; recent .r-ray treatment ;
the external application of any liniment,
ointment or lotion other than vaseline, lano-
lin or cold cream. It does not seem advisable
to give .r-ray treatment during the active
stage of an acute infection or immediately
after applying nitrate of silver, iodine or any
local irritant to the tonsil.

With the present day methods of measur-
ing .r-rav dosage and the constancy of the

Coolidge tube and
interrupterless ma-
chine, the dangers
of the gas tube and
the .I'-ray coil are
practically elimin-
ated. A Doctor's de-
gree, years of ex-
perience in nose and
throat, or even in
radiography (.r-ray
plates), do not au-

FlG. 9.

X-Ray Treatment of Tonsils and Adenoids

tomatically fit any one for the practice of
^-ray therapy.

On the other hand if the treatment is
properly given as indicated, and the time
lessened in both the massive and fractional
methods of dosage in accordance with the
age of the patient, there is not the sHghtest
danger of injuring the skin or any of the ad-
jacent structures, as exemplified in the re-
sults obtained for the past twenty years in
the treatment of ringworm of the scalp. The
immediate and after-effects of excision of
the tonsil seem severe as compared with the
x-vs.y treatment, which may produce dryness
of the throat and a feeling of stiffness in the
muscles of the neck. These symptoms are
only apparent to the sensitive individual
when the massive dose is used.

The extent of any after-effects of discom-
fort might be explained by citing the case of
a young man to whom I gave three massive
doses between 4 and 5 p. m., and that night
he won the one-mile amateur championship
in a local armory.

Recently Dr. Thomas R. French "* has em-
phasized the presence of chronic infectious
material in the crypts of the infratonsillar
nodule as a possible source of systemic infec-
tions, and advocates their removal even
though the operation is more extensive than
that of tonsillectomy.

The infratonsillar nodules or tonsillar
branches (Fig. 9) may overlap the under
surface of the posterior lateral halves of the
inferior lobes of the tonsil.

Those structures frequently referred to as
infiltrates or recurrent tonsils are really
nothing more than extended and expanded
ends of these lymphoid bodies. The fossa, or
space between the pillars left after removal
of the tonsil, may be subsequently filled by
the infratonsillar lymph nodule with its in-
fected crypts. The infratonsillar nodes may
progress in size as the tonsils themselves
diminish or atrophy. Those nodes in some
cases may be larger than their associated
atrophied tonsil.

If the infratonsillar nodule with its
pharyngeal and lingual branches (Fig. 9)

exhibits all the characteristics both patho-
logically and histologically of the tonsil as
indicated in the above article * with the re-
sults so far obtained with .r-ray on tonsillar
tissues, does it not seem reasonable to infer
that not only will cases treated with A--ray
have their tonsils reduced and crypts evacu-
ated, but that the same process will prevail
in the infratonsillar nodule, thus more thor-
oughly removing the focal infection than by
tonsillectomy and that by this means better
results will be obtained in combating those
systemic infections dependent on this con-
dition, namely, rheumatism endocarditis,
chorea, septicemia, etc. ?

The results of the study thus far open up
possibilities of the .r-ray in connection with
tonsillar disease. One hopeful assistance is
in the diagnostic value in determining the
relationship between the focus and a given
systemic infection, more especially those in-
fections in which pain is a prominent symp-
tom. If the bacteria are the causative factors
of such pain, it would stand to reason that
their evacuation would be followed by par-
tial or complete relief. In such an event the
most rational treatment could be definitely
decided upon. Another hopeful assistance
from the ,r-ray is to be considered in the pos-
sible evacuation of bacteria from the crypts
of the tonsil in carriers, especially those of
diphtheria and influenza. For it is hardly to
be supposed that these bacteria would recur
after such evacuation except by reinfection.

CONCLUSIONS

It would seem probable that .I'-ray treat-
ment will be indicated in cases of diseased
tonsils and infratonsillar lymph-nodes asso-
ciated with chronic endocarditis pericarditis,
hemophylia, or any co-existing conditions
which contra-indicate operation or an
anesthetic.

We know that after tonsillectomy in sub-
jects above the sixth or eighth year, and es-
pecially in adults, there still remains a con-
siderable and possibly a vast amount of dis-
eased lymphoid tissue containing pathogenic
bacteria, in which cases it would seem reas-

An Inexpensive Radium Capsule Holder

onable to believe that the .r-ray will prove to
be of value.

It must be understood that this paper is
only suggestive, and that the permanency of
the results time alone will determine. But the
facts in so far as the experimental work has
been carried out are presented.

BIBLIOGRAPHY

I. Murphy, James B., M.D., Witherbee, W. D.,
M.D., Craig, Stuart L., M.D., Hussey, R. G.,
M.D., AND Sturm, Erxest. The atrophy of hy-

pertrophied tonsils and other lymphoid struc-
tures of the throat induced Iw small doses of
.v-ray. /. Am. M. Assn., Jan., 1921.

2. Kellert, Ellis. The pathological histology of ton-

sils containing hemolytic streptococci. /. Med.
Research, xli. No. 4, pp. 387-398, May, 1920.

3. Witherbee and Remer. Filtered .t'-ray dosage.

.V. York M. J., cxi, No. 26, June 26, 1920.

4. French, Thomas R. Retention crypts in the infra-

tonsillar nodules as harbors of pathogenic bac-
teria. N. York M. J., cxi. No. 25, pp 1057- io55,
June 19, 1920.

5. Witherbee and Remer. Filtered and unfiltered

.r-ray dosage. Am. J. Roentgenol., vii, 485, Oc-
tober, 1920.

AN INEXPENSIVE RADIUM CAPSULE HOLDER

By GEORGE E. PFAHLER, M.D.

PHILADELPHIA, PENNSYLV.\NIA

' I "'HERE is much risk in handling the
-■- capsules containing radium element,
and in the process of screwing these capsules
together or separating them there is unneces-
sary exposure of the fingers to danger. Any
device that will help to keep the fingers at a
distance will be useful and will lessen dam-
aging effects. Several capsule holders have
already been designed, but each one will fit
only the caj^sule for which it has been made.
I therefore searched in instrument stores and
elsewhere, but linally went to the hardware
store where I found a chuck which is 103/2
cm. in length and which can be adjusted to
take any of the capsules varying from 4 to
6.3 millimeters. The cost of this chuck is
85 cents, plus the labor of drilling the soft
jaws. It is necessary to drill out the chuck in
its central portion so that when it is wide
open it will just grasp the largest sized cap-
sule. This chuck is superior in my experience
to the instruments made costing $12 to $15.
It can be lengthened as much as desired by
setting the handle into a wooden handle
(Fig. i). The remainder of the metal, if de-
sired, may be covered with rubber. Having
just spent twenty-five dollars for a pair of
instruments that will not even grasp one size
of capsule satisfactorily, I naturallv "en-
thuse" over the above little instrument.

FiG. I. GdiinKi.L 1'katt Co. Second Size Drill C'hltk.
Will take any size capsule. Wood handle can be
attached as shown in this figure.

Fig. 2. Starett Pin Vise Gr.a.sping one of the
Radium C.\psules.

Fig. 3. The Same Pin Vice with Cap Removed,
showing the jaws which have been drilled out suf-
ficiently to take varying sized capsules.

TWO UNUSUAL CHEST CASES*

Bv JOHN G. WILLIAMS, M.D.

BROOKLYN, NEW YORK

/"^ASE I. History. — First seen by Dr.
^^ A. A. Rutz, April ii, 191 7. Female,
age forty-eight. Married, and prior to her
marriage a public school teacher.

Past History. — Fifteen years ago she had
malaria, and ten years ago typhoid fever.
She had never had diphtheria. There have
never been any paralyses. Her menstrual his-
tory is negative, except that recently the
periods have been prolonged.

She has always been of nervous tempera-
ment and suffered from gastro-intestinal dis-
turbances. She was irritable and subject to
emotional attacks of crying and laughing.
These attacks in later life were followed by
mental and physical prostration, necessitat-
ing rest in bed. At various times she has
suffered from pain in the back of the neck
and numbness and pain in various regions of
the body. There was also insomnia and im-
pairment of memory. She has alwavs been
constipated. Excessive secretion of saliva
has been noted for years.

Fourteen }-ears ago the patient saved a
child from strangulation, a particle of food
having entered the child's respiratory pas-
sage. This incident impressed itself so firmly
on the patient's mind that, from this time on,
she suffered from a constant fear of chok-
ing during her meals. At times this fear be-
came so strong that it interfered with her
deglutition. These disturbances of degluti-
tion were always slight and transitory in
character and consisted of sudden regurgi-
tation of food from the esophagus, occa-
sional coughing and choking, and the en-
trance of food into the nares. Her chief com-
plaint at the time she consulted Dr. Rutz
was belching of gas.

Physical examination at this time showed
a few rales at the base of both lungs, a pal-
pable right kidney and tenderness over the
cecum and ascending colon. The knee-jerks
were exaggerated.

On April 20th a test breakfast was given,
following which a stomach tube was intro-
duced and the contents of the stomach re-
moved without difficulty.

On April 21st a test dinner was given to
determine the gastric motility. A No. 23
French stomach tube was introduced without
difficulty, but aspiration was impossible, and
inflation showed that the tube was not in
the stomach. The tube was removed and
again inserted, with the same result, but it
was noted that air passed through the tube
with respiration. From this it was deduced
that the tube was in the trachea and was
removed. The patient was asked to swallow,
but was unable to do so, as evidenced by
failure of the larynx to move. Further exam-
ination showed that there was complete anes-
thesia of the pharynx and larynx. The gag
reflex was absent and the insertion of
the tube into the trachea caused no reflex
cough or discomfort to the patient. The dif-
ficulty in deglutition was, at that time, con-
sidered temporary and unimportant, and was
attributed to the patient's nervous condition,
as she had looked forward to the examina-
tion with considerable apprehension.

On April 27th Dr. Rutz w^as called to the
patient's home, as her condition had assumed
a more serious phase. She was found sitting
up in bed, suffering from considerable dys-
pnea and cyanosis, and imbued with the idea
that her dvspnea was due to distention of
her stomach. She was belching large cjuan-
tities of air.

Examination of the abdomen showed no
undue distention of the stomach. There was
a large number of coarse mucous rales over
both lungs. The physical signs in the chest
were suggestive of pulmonary edema. Tem-
perature, 1 01. 6. Pulse, 130. Respiration, 36.

The patient was given water to swallow,
but no deglutition sounds could be heard at
the ensiform. Following this, the dyspnea

'Thesis presented with application for membership in The American Roentgen Ray Society, 1920.

Two Unusual Chest Cases

and other chest signs increased. The cause,
nature and seriousness of the patient's con-
dition were recognized. The disturbance of
degkitition previously observed had persisted
so that her food was entering the trachea,
and thereby interfering with respiration and
subjecting the patient to the danger of pul-
monary infection. Dr. Rutz now sent the
patient to St. Mary's Hospital for treatment
and observation. Rectal feeding was resorted
to at first and later it was found possible, by

Fig. I. Case i. Bismuth in Both Lungs and also in
Larynx.

the use of a stiff er tube, to pass the same
into the stomach, and the patient was fed in
this way. Excessive secretion of saliva was a
constant symptom at this time, but was con-
trolled by belladonna. Her pulmonary symp-
toms rapidly cleared up and later her respira-
tory passages showed a marked tolerance to
foreign material of various kinds. Various
colored solutions were given and later
coughed up. At one time six ounces of cus-
tard were apparently retained in the respira-
tory passages for twenty minutes and then
gradually brought up by coughing.

On May loth the writer examined the

patient at the hospital. Two ounces of bis-
muth mixture were given the patient to swal-
low, and on the screen it was seen that most
of this entered the trachea and thence on
into the bronchi of both lungs. It apparently
caused the patient no distress, and she did
not cough as a result of it. Stereoscopic
plates were then made, and it will be seen
from these that the bismith mixture entered
the lower lobes of both lungs extending well
out into the smaller bronchi. Some few hours
later, the patient coughed up much of the
bismuth, and two days later the stereoscopic
plates showed no trace of it in the respira-
tory tract.

For three weeks during her stay in the
hospital complete aphagia was present. At
the end of this time the patient began to
swallow normally with occasional remis-
sions, so that at times she had to be fed by
tube. She was allowed to return home after
four weeks' stay in the hospital, and a mem-
ber of her family was instructed how to
pass the tube and tube- feeding was continued
for some time after leaving the hospital.
The aphagia suddenly ended when one
morning, at breakfast, she had an uncon-
trollable desire to drink some tea. She drank
three cupfuls in succession, and from this
time on had no difficulty in swallowing.
When last seen, December i, 191 7. she was
swallowing in a perfectly normal manner.
Sensation had returned to the pharynx and
larynx and none of her former symptoms
were present.

The diagnosis in this case, made by Dr.
Rutz before referring the case to the writer,
is hysterical aphagia. The loss of sensation
in the pharynx and larynx eliminated the
second stage of deglutition, and the larynx
was not elevated and protected by the epi-
glottis, so that, through gravity, the material
swallowed dropped directly into the larynx.
The retention of foreign material for so long
a time in the bronchi indicates that there was
diminished sensation here also. Difficulty in
degkitition is not uncommon in hysteria and
is mentioned in all of the text books on ner-
vous diseases.

Two Unusual Chest Cases

On looking up the literature, however, I
am unable to find any cases reported in
which .r-ray examination revealed the con-
dition as shown here, except a case reported
by Pancoast in The American Journal of
Roentgenology, March, 191 8, which may
be of the same type. He merely says, in re-
gard to the case, that the girl was referred
for supposed esophageal stricture, but the
obstruction in the esophagus was neurotic
in origin.

complains of soreness in the right hypochon-
drium, most marked soon after eating; also
some gnawing sensation in the chest, behind
the heart. These are relieved by belching of
gas after taking alkalies. Occasionally, dur-
ing the past few years he has had to bring
on vomiting by tickling the pharynx to get
relief. Of late the symptoms have been more
constant and recently, having had a bron-
chitis, he noticed a tendency to regurgitation
when he coughed, especially when lying

Fig. 2. Case 2. Plate made before meal showing Fig. 3. Case 3. Right lateral view showing stomach
dilated stomach and esophagns in right mediasti- and esophagus with penetrating ulcer on lesser

num. curvature of stomach just above incisura.

Case II. Referred by Dr. E. P. Porter,
for examination of the stomach and duode-
num, January 30, 1920.

History. — ]\Iale, age fifty-eight; occupa-
tion, salesman.

Previous History. — Negative, except for
ordinary diseases of childhood. For the past
twenty years or more the patient has had
more or less digestive disturbances. These
consisted of some difficulty in swallowing,
in that he had to eat or drink slowly because
of some distress in the mediastinum when-
ever he tried to eat or drink rapidly. He

down. He has never noticed blood in the
vomitus, which usually contained food taken
several hours previousl}'. His weight was
constant up to one year ago, but in the past
vear he has lost about ten pounds. The bow-
els are constipated. Xo history of acute ab-
dominal or chest symptoms and no history
of injurv to the thorax or abdomen.

On screen examination, there was oh-
served an al:)normal shadow in the right
chest, extending from the right clavicle to
the diaphragm. The margin of this was
smooth, except for an indentation opposite

Two Unusual Chest Cases

the right second interspace. The left margin
of this shadow was fused with that of the
heart and vessels of the mediastinum. On ro-
tating the patient, it was observed that this
abnormal shadow was in the posterior
mediastinum. The barium meal was observed
to enter the upper portion of this shadow
region and was delayed here for two or three
seconds and then continued on into the lower
part of the shadow, none of it passing belov-
the diaphragm. Meanwhile, a considerable

plates were also made in most of the posi-
tions above enumerated with a barium meal
in the chest.

The plates made without barium in the
chest show that this abnormal shadow in
the mediastinum is not very dense, as the
bronchial tree on the right side may be seen
through this shadow. Stereoscopically, it is
seen to be tubular and apparently contains
air in the lower two-thirds, there being less
marked distention above. In the plates made

Fig. 4. Case 2. Six hour plalc. Duly Mnall amount
of barium in intestine.

Fig. 5. Case 2. Twenty-four hour plate. Stomach
empty, most of meal being in colon.

portion of the meal connected in the upper
sac.

Plates were now made in various posi-
tions, such as standing direct, oblique and
lateral ; prone direct, oblique and lateral. An
attempt was made to examine the patient
on an inclined plane with the head lower
than the feet, but he could not retain the
meal in this position. Plates were made six
hours after the meal, twenty-four hours af-
terward and forty-eight hours afterward.
Stereoscopic plates of the chest were also
made on one of these later visits when the
chest contained no barium. Stereoscopic

directly with the patient [)rone, most of the
barium is seen in the lower mediastinum, be-
hind the heart shadow. There is some barium
also in the upper sac. In this position, the
lower shadow assumes the shape of the
stomach. In the right lateral position, with
the patient lying on his right side, the lower
sac seems to be the stomach ; and the pylorus
and antrum are visible, as well as the greater
and lesser curvatures. All of the plates made
in this position show a projection from about
the middle of the lesser curvature suggesting
a penetrating ulcer or adhesion here. The
lower sac .shows several indentations on both

Two Unusual Chest Cases

sides, evidently peristaltic waves. The upper
sac also shows sharp bilateral indentations
suggestive of the haustral markings of the
colon. In the plates made with the patient
standing, little of the barium remains in the
upper sac. The six-hour j)late shows most of
the meal still in the chest, a small stream
being visible in the small intestine Ixdow the
diaphragm. The twenty-four hour plate
shows most of the barium distril)uted
throughout the colon, with a small amount
remaining in the terminal ileum. The pa-
tient's bowels moved spontaneous!)' at thirty
hours, so that later plates showed only
traces of the meal in the colon.

From the above findings, I believe that the
shadow in the right mediastinum is due to
the presence here of the stomach and dilated
esophagus above it. There is very little of the
small intestine above the diaphragm. The
dilatation and hypertrophy of the esophagus
are due to constriction of the cardiac end of
the stomach. The stomach empties some time
between six and twenty-fovu^ hours (unable
to get intermediate plates). The defective
motility of the stomach is due to constric-
tion of the small intestine, at the opening in
the diaphragm, and spasm of the pylorus as
a result of the lesion on the lesser curvature.

The small intestine is practically empty
at the end of twenty-four hours. The con-
dition now present has probably existed for
many vears. There is no history of trauma
and no histor}- of acute abdominal crisis. For
this reason, it would seem that the stoniach
probably passed through one of the normal
openings in the diaphragm, most probabl)"
the esophageal and that the esophagus was

carried up into the chest with the stomach.
Hernia of the stomach and other abdom-
inal viscera through the diaphragm was, un-
til recent years, considered cjuite rare. How-
ever, since the advent of .i"-ray examination
of the hollow viscera, the number of cases
reported has markedly increased. Particu-
larh- is this true since the recent war. Neces-
sarily there were many wounds of the dia-
phragm, and as a result of these there have
been many cases reported of hernia through
these wounds, and some of these cases were
not recognized until the patients had been
through several hospitals. The cases difficult
of diagnosis, even with .r-ray examination,
are those in which the opening in the dia-
phragm is small and a part only of the stom-
ach or intestine is involved. Soresi has re-
centh' reported such cases.

REFERENCES

C.\SE I. Paxcoast. Am. J. Roextgexol., March,

1918, V, 130.

CASE II. De Courcy, J. L. Ann. Surg., 1919, Ixx,
179.

Baimgartxer. -A. and Herscher. Bull, ct man.
Soc. de cliir. dc Par., 1919, xlv, 185-194-

Gaudier, H. Idem. 1919, xlv, 939-951.

Weidxer, C, and Weidxer, Jr. Kentucky M. J.,

1919, xvii, 42-44.

Hayes, M. R. .1 . Med. Press, London, 1919. i, 767-
.\uvRAY. Bull, et mem. Soc. de cliir. de Par., 1919.
xlv.

DujARiER, C. Idem, 1919, xlv, 787.

Lefevre axd Mauclaire. Idem, 1918, xliv, 1855.

MoxRAD, Ugesk. f. Lxger, Kjobenh., 1919, Ixxxi,

456.

Ware, J. G. J. Am. M. As.<;n., 1910, Ixiii, 267.

Warrex, R. Lancet, Lend., 1919, i, 1069.

Grange, C. D. Brit. J. Surg., 1916, iv, 604-606.

SiMONDS, C. /. Roy. Army Med. Corps. Lond., 1917,
xxii, 369.

Soresi, A. L. Ann. Surg., 1919, Ixx, 254.

THE AMERICAN JOURNAL OF ROENTGENOLOGY

Published by Paul B. Hoeber, New York City

Issued Monthly. Subscription, $6.00 per year. Advertising rates submitted on application.
Editorial office, 480 Park Av., New York. Office of publication, 67-69 East 59th St., New York.

Official Organ of
THE AMERICAN ROENTGEN RAY SOCIETY

President
Arthur C. Christie, M.D.,

1621 Connecticut Ave., Washington, D. C.

First Vice-President
A. H. PiRiE, M.D.

Royal Victoria Hospital, Montreal, Canada

Second Vice-President
C. A.. Waters, M.D., iioo N. Charles St., Baltimore

Secretary
H. E. Potter, M.D., 122 S. Michigan Ave-, Chicago

Treasurer
W. A. Evans, M.D., 32 Adams Ave. W., Detroit

Executive Committee
Henry K. Pancoast, M.D., Philadelphia, Pa.

Alexander B. Moore, M.D., Rochester, Minn.

W. B. Bowman, M.D., Los Angeles, Cal.

Publication Committee
Isaac Gerber, M.D., Providence, R. I.

Leopold Jaches, M-D., New York City

P. M. HiCKEY, M.D., Detroit, Mich.

Librarian and Historian
H. W. Dachtler, 224 Michigan St., Toledo, Ohio.

Editor
H. M. Imboden, M.D. 480 Park Ave., New York

Associate Editor
Percy Brown, M-D., Boston, Mass.

Annual Meeting Eastern Section

The Second Annual Meeting of the Eastern
Section of the American Roentgen Ray Society
will be held in Atlantic City at Haddon Hall-
Chalfonte, on Friday evening and Saturday,
Jan. 28, 29, 192 1. Make hotel reservations
early, mentioning American Roentgen Ray
Society.

Communications regarding the program
should be addressed to Dr. David R. Bowen,
82 West LaCrosse Ave., Lansdowne, Pennsyl-
vania.

In all other matters concerning this meeting
address Dr. Joseph M. Steiner, 103 Park Ave.,
New York Citv.

Annual Meeting Central Section

The Second Annual Meeting of the Central
Section of The American Roentgen Ray
Society will be held on February 21, 1921, at
St. Louis, Missouri. Announcement of head-
quarters will be made later.

Communications regarding the program
should be addressed to the president, Dr. James
G. Van Zwaluwenburg, Ann Arbor, Michigan.
The chairman of the local committee, Dr.
Edwin C. Ernst, 412 Humbolt Building,
St. Louis, may be addressed concerning mat-
ters of arrangements.

THE CALDWELL LECTURE

The American Roentgen Ray Society
has sought to honor some of its former
members, martyrs to their profession. Two
thus far honored are Leonard and Caldwell.
At the last annual session, a Leonard prize
was voted, details of which will be found
elsewhere in this number. Eugene W. Cald-
well's work placed him in the foremost
rank of American medical scientists, and
it is highly fitting that each year the
memory of our beloved co-worker shall be
freshened by a lecture given in his name. It
is planned to have an hour set apart on each
annual program for a formal lecture on
some topic relating to roentgenology or
radiumtherapy, the speaker to be chosen by
the president each year. For the first
Caldwell lecture at Minneapolis, Minnesota,
Thursday afternoon, September 16, 1920,
we had the honor and the privilege of hear-
ing Dr. Walter C. Alvarez, Assistant Pro-
fessor of Research Medicine, George
Williams Hooper Foundation for Medical
Research, LTniversity of California Medical
School, San Francisco, California, on "Per-
istalsis in Health and Disease," whose paper
appears in this number. James T. Case.

Editorials

COMMUNICATIONS

PARIS LETTER

TOURING the course of the war a large
^^ number of French and American radi-
ologists had occasion to meet and to work
together in the various medical organizations
at the front and in the interior. Thus were
established those sympathetic and friendly
personal relations which make it more desir-
able than ever that they keep in touch with
each other and that they reciprocate in their
labors and their researches. Constantlv in-

radiologic activities; and he takes this occa-
sion to congratulate his colleagues, particu-
larly Drs. Hickey and Imboden, on their
initiative in creating this new department.
He will endeavor to present in these ar-
ticles all that is new and interesting in
France in the various domains of radiology
and radium therapy, and at the same time he
will seek to inform those in the United
States who may have occasion to come to
France as to the hospital services and the
laboratories which they will find it most
profitable to visit.

i-ii.. I. Due DE Broglie.

formed by his faithful and eminent friends
of the remarkable development of radiology
in the United States, and endeavoring to
pass on to those about him all that he thus
learns, the author of these lines has long
hoped that his colleagues in the United States
might come to take an equal interest in
French radiology.

He therefore accepted joyfully, in spite of
very numerous duties, the proposition trans-
mitted through Dr. Beclere, Master and
Dean of French radiology, to write for the
readers of The American Jourxal of
Roentgenology a monthly letter from
Paris portraying as faithfully as possible our

Fig. 2. Dr. A. Dauvillier at Work in the
Laboratory.

Modern research tends to show that all
progress which may be made in the applica-
tion of the .r-rays to medical diagnosis and
treatment is inseparable from physical re-
search, and that all productive work thus ne-
cessitates the active and continued collabora-
tion of the physicist, the constructor and the
radiologist — that is, the constant union of
theory and practice.

One of the first to perceive clearly this
necessitv was the eminent physicist M. Vil-
lard, of the Academy of Science, to whom
we owe the discovery of the gamma rays of
radium, the invention of the osmo-regulator,
and the appearance in 1908 of the first ap-

Editorials

paratiis for the measurement of the .r-rays
by ionization. We owe to Dr. Coohdge. to-
gether with the most important advance in
radiologic technique since Roentgen's discov-
ery, certain facihties for experimentation
which profit medicine and physics ecptaliy.
and which give a new impetus to the col-
laboration of these two sciences.

A number of French radiologists, there-
fore, have thought the moment well chosen
for the establishment of a laboratorv for re-

ance of the laboratory, and assumes the sci-
entific direction of it.

Dr. M. A. Dauvillier, a young physician
of great future, already known by his inter-
esting work with the .r-rays, is attached to
the laboratory. Some of the readers of this
letter will perhaps remember having seen
him during the war in the .r-ray department
of the Descartes hospital at Tours, where we
first realized the value of an intimate relation
between a physical laboratory and a medico-

FiG. 3. View of Research Room in the Laboratory, Showin'g in the Background
High-tension Tr.-xnsformer with Kenotrons and Condensators for Continu-
ous High-tension Work. A quartz tube and the Abraham-Villard voltmeter
arc visible in the center, whilst the vacuum pump shows in the foreground.

search in the field of .r-rays, and to facili-
tate the study of all cpiestions which may di-
rectly or indirectly interest either physicians
or technicians.

The Due de Broglie, well known for his
spectroscopic studies of the .t'-rays. and who
has at present for his personal use a well-
equipped laboratory, has generously ofifered,
to shelter the new organization, an entire
building completely furnished and eciuipped
with the most excellent and modern appa-
ratus. Except for the very modest assist-
ance of the writer, the Due de Broglie over-
sees entirely the functioning: and mainten-

surgical .r-ray service. For, modest as it was,
that laboratory where so often Colonel
Shearer lavished upon us the precious coun-
sel born of his long experience, was the
scene of some research work which the
Academy of Science viewed with interest,
and the continuation of which it encouraged
with an important prize.

We may hope, therefore, that under the
direction of the Due de Broglie, and profit-
ing by his large experience, the laboratory
will not delay in giving proof of its utility.

To describe it briefly, it is housed in a
building having a basement and two stories.

Editorials

In the basement are a preliminary vacuum
apparatus (a motor and a pump working in
oil), and a converter for changing no V".
D.C. into 250 V. single phase alternating
current of 600 periods (60 cycle.^). This
group has a capacity of 5 K.\\ A.C. The
ground floor includes an office, a dark room,
and two laboratories. The smaller labora-
tory is at present reserved for the study of
Lilienfeld apparatus. The larger one con-

cludes a Bragg spectrometer and a Broglie
spectrograph. These permit the simultaneous
analysis of rays from two sources enclosed
in lead boxes of about one cubic centimeter
capacity, and having a wall thickness of 15
mm. Two other pieces of spectroscopic ap-
paratus, including a monochromateur, and a
spectrograph of special precision for the
study of very short wave lengths, are under
construction.

Fig. 4. Another Part of Research Room, showing the quartz vacuum pump and
Gaede pump on the right, the large lead box (weighing over a ton) in the
center, and the spectrometers on the left.

tains (a) a coil with mercury interrupter
working on the no V". D.C, and (b) a Gal-
lot-Gaiffe transformer working on the 120
V. single phase alternating current, and
which can supplv the incandescent cathode
type tubes with a maximum of 170 K.V.
controlled by an auto-transformer. Voltages
are measured by an Abraham-Villard elec-
tro-static voltmeter. This laboratory h?s also
facilities for pumping vacuum tu]:!es, namely,
a special quartz condensation pump, with a
Gaede rotarv pump for preliminary pump-
ing, permitting the obtaining of very high
vacuums with considerable speed ; and a
Pilon apparatus.

The spectroscopic apparatus in use in-

The experimental tubes used are almost
exclusively constructed of cjuartz.

The researches undertaken by the labora-
tory are not confined to purely theoretical
phvsics. An important place is reserved for
all questions of interest from the medical
viewpoint, and particularly for radiotherapy,
which is closely connected with the study of
ravs of very short wave length.

Finally, the laboratory, endowed with a
verv complete library, may be regarded (al-
though not public) as a center where work-
ers lacking information on certain points of
physics of radiology may bring their prob-
lems, and continue their researches.

If the readers of this first letter reproach

Book Reviews

us with having dealt exclusively with phys-
ics, we hope that Dr. Coolidge, who mani-
fested his interest in the new creation when
he visited it last August while it was under
construction, and who considered it to be the
only institution of its kind in the world, will
deign to say a few words in our defense. He
will agree with us perhaps that the future of
radiology, and particularly of deep radio-
therapy— a domain as vast as it is interesting
— depends entirely upon the close collab-

oration of the physician and the physicist.
The description we have given will serve
as an introduction to the letters which will
follow, and if it has seemed wearisome to
some of our American colleagues because
we have not spoken of medical radiology, we
hope they will pardon us, and we promise
them that we will not stray into the domain
of physics again for a long time.

Dr. R. Ledoux-Lebard.

BOOK REVIEWS

The Story of the American Red Cross in
Italy. By Charles M. Bakewell. Pages 225.
Illust. Price, $2.00. Macmillan Co., 1920.

This most attractive volume is a faithful
history of the accomplishment of the American
Red Cross in Italy beginning with May, 191 5,
the date of Italy's entrance into the war, and
continuing the narrative until up to the middle
of 1919, when Red Cross war activities were
practically closed in Italy. The book tells not

only of the establishment of relief centers,
work-houses, traveling canteens, "asili" for
children and large hospitals, but also of the
building of entire cities for the accommoda-
tion of refugees from the Piave and from
Venice. It is highly fitting that the accom-
plishments of the American Red Cross should
be thus chronicled. We hope there will be a
wide distribution of this work.

James T. Case.

Subscribers to The American Journal of Roentgenology visiting l^ew Tor\ City, are in-
vited to ma\e the office of The Journal (69 East 59th Street, 'Hew Tor/^ their headquarters. Mail,
packages or baggage may be addressed m our care. Hotel reservations will gladly be made for those
advising us in advance; in this case, \indly notify us in detail as to requirements and prices. List of
operations in T^ew Tor\ hospitals on file in our office daily.

TRANSLAriOXS ^^ ABSTRACTS

LovETT, Robert W., and Wolbach, S. B.
Roentgenographic Appearance, Diagnosis,
and Pathology of Some Obscure Cases of
Bone Lesions. (Surg., Gynec. and Ohst.,
Vol. xxxi, No. 2, August, 1920.)

For the past five years the writers have been
concerned in a conjoined study of certain ob-
scure bone lesions, occurring in the orthopedic
service of the Children's Hospital. In cases
where the diagnosis of a bone lesion was in
doubt, the pathologist has been present when
operations were to be performed, and has
taken his own specimen when the bone was
opened, so that if possible an immediate diag-
nosis could be made by frozen section, and the
operative wound treated accordingly. When
the pathologist could not make a diagnosis in
this way, the specimen was taken to the labora-
tory, studied, and reported on later. The cases
presented are those in which there was, in the
minds of the writers, doubt as to the correct
diagnosis from the ;r-ray and other data avail-
able before operation. Each case is presented
with a short clinical history, an ;r-ray and a
pathological report. The writers are indebted
to Percy Brown, radiologist of the Children's
Hospital, for co-operation in the study, and to
John J. Morton, of Boston, also a hospital
associate, for much labor in the collection and
arrangement of the data. Considering the be-
havior of bone in general, as studied by the
x-vdi\, it seems to be a structure of very lim-
ited reaction to pathological conditions. Re-
garded from this point of view, there seem to
be only three reactions possible in bone. These
are : ( i ) atrophy or diminution in line content ;
(2) destruction of bone tissue, local or gen-
eral; (3) a formative process, characterized
by formation of new bone, or a condensation
of existing bone around a focus of disease.
The general point of view with regard to these
processes has been that tuberculosis is largely
destructive in character ; that the tuberculosis
is characterized by marked atrophy of the af-
fected bone, with perhaps atroph\- of contigu-
ous bones in the same limb ; and that it occurs
in the region of the epiphysis. Osteomyelitis
has been generally regarded as a process at
first destructive in character, and then forma-
tive, the formative process generally becoming

dominant. Syphilis has been considered as the
most purely formative of the three processes,
with some element of destruction, but much
more formative than either of the others men-
tioned. When the writers attempted to study,
from the point of view of pathological find-
ings, .ar-rays taken of cases prior to operation,
it became evident that this criterion could not
be depended upon ; that tuberculosis, which has
ordinarily been spoken of as occurring in the
articular ends of bones, might occur in the
shaft, and that it might be almost a purely
formative process, or that the formative pro-
cess might exist with the destructive process,
and ultimately become dominant ; and that a
local destructive process, indistinguishable
from the so-called Brodie's abscess, might oc-
cur in a pure tuberculosis, so that a localized
cavity in bone, well walled off, might occur in
this disease. It appeared also that a wedge-
shaped destruction in the articular end of the
bone, with the base of the wedge toward the
joint, might occur both in tuberculosis and
osteomyelitis, and that under these circum-
stances the two were practically indistinguish-
able. The errors in diagnosis, in the experience
of the writers, have more often consisted in
mistaking tuberculosis for other things than in
mistaking other things for tuberculosis. A cu-
rious punched out lesion of the skull was
identified pathologically in two cases as being
definitely tuberculosis. The other confusion
which was most troublesome arose between
osteomyelitis and spyhilis, two cases involving
the lower end of the fibula being shown which
were in .r-ray appearances practically identical.
Again, the stage of repair in osteomyelitis may
be seen in the .r-ray of two tibiae to be very
similar in spyhilis and osteomyelitis. As it has
appeared to the writers, the problem of dififer-
entiating the three conditions mentioned by
means of the .r-ray, is not encountered, as a
rule, in the routine case in which a purely de-
structive lesion is most often tuberculosis. The
lesion of rapid destruction, with marked for-
mative activity, is generally osteomyelitis, and
the purely formative process is most likely to
be syphilis. The serious problem of dififeren-
tial diagnosis occurs most often in cases in
which focal lesions are present, in which the
phenomena of formative and destructive ac-

Translations and Abstracts

tivity have become so mixed that without the
pathological examination, in many of them the
diagnosis is impossible. The advantage of such
a diagnosis made during the operation is evi-
dent to any surgeon, because it guides him in
the treatment of the bone cavity, and is often
the direct factor in deciding whether or not to
close such a cavity. In addition to the three
conditions of tuberculosis, osteomyelitis, and
syphilis, certain other bone lesions are shown,
which have a bearing on the question of diag-
nosis. A short summar}- of the case histories
will be presented, the salient pathological facts
discussed, and conclusions drawn as war-
ranted.

DISCUSSION

riie diagnosis of infectious lesions of the
bones would be simple if each infectious agent
always produced the same reaction. The p}0-
genic bacteria alone ma}- be counted upon to
conform to t\ i)e ; at first destruction of tissue
followed b\ repair, which in the case of bone
means necrosis with more or less local disap-
pearance of lime salts, followed by new bone
formation from adjacent healthy bone struc-
tures. It must be remembered in the reaction
of bone to injury that new formation of tissue
is always followed by ossification and therefore
that gra^nulation tissue from bone or perios-
teum becomes bone tissue. The above simple
sequence in the pyogenic infections accounts
for the definite criteria applicable in osteomxe-
litis. It is conceivable that a rapid healing of
a small abscess in bone might result in very
little granulation tissue production from adja-
cent tissue with very little production of new
bone. Syphilis affects the bone in two wa\s,
both effects of the proliferative reaction of the
casual agent, and results either in the destruc-
tion of bone, or the new formation of bone.
Both effects may occur in the same case. De-
struction of bone follows the formation of lo-
cal, rapidly-formed gummatous lesions, some-
times of endosteal and periosteal origin, some-
times perivascular and extending into bone. On
the other hand, the degree of reaction to the
spirocheta may be slight and result only in
proliferation of cells of the periosteum and
endosteum, the newly-formed tissue develop-
ing osteoblasts and eventually new deposit of
bone is the result. In one case, therefore, there
is choking of normal bone by the gummatous
process with its necrosis ; in the other case

there is merely stimulation of bone-forming
tissue. Tuberculosis presents more possibil-
ities. In soft tissues it is known that the tu-
bercle bacillus can duplicate the reaction of
almost an\- t_\pe of pathogenic bacterium. Thus
the various types of exudati\e response to in-
jur}- may be the result of the tubercle bacillus
alone ; exudates essentiall}- fibrinous or essen-
tiall}- puriform in character are frequently
found upon serous membranes — meninges,
peritoneum, pleura, and pericardium. In bone
we usually think of tuberculosis as a prolifera-
tive process resulting in the new formation of
tissue with consequent obstruction of the bone,
and this is the commonest t}-pe of tuberculous
bone lesion which gives rise to the formation
of bone cavities without a peripheral reaction
or condensation of bone.

In tuberculosis of bone, as in soft tissues,
there ma}- occur : ( i ) Exudate, fibrinous or
puriform, (2) discrete proliferative lesions,
the tubercle which may progress slowly or
rapidl}- with much or little caseation, and (3) a
diffuse proliferative reaction, following the ex-
udative— essentially tuberculous granulation
tissue, with much or little caseation. In the
third instance, in the granulation tissue, there
ma}- be new bone formation just as in the re-
pair of pyogenic processes, at a time when de-
struction or resorption of bone is going on.

The important lesson from the pathological
studv of this series of cases is the reminder
that tuberculosis in bone ma}- simulate any
other infectious process in location and charac-
ter of the lesion. Diagnosis from .t'-ra}- studies
alone is therefore occasionally impossible and
recourse must be had to other clinical evidence,
and when possible to pathological examination.

Carman, R. D., Mayo Clinic. The Roentgen
Diagnosis and Localization of Peptic Ulcer.
(Calif. State J. of Med., November, 1920,
A'ol. xviii, Xo. II.)

AIan\- roentgenologists refuse to make a
diagnosis in the absence of direct signs, and
claim that complexes made up of indirect signs
are of no value. This view is far too radical,
for if roentgen ra}- diagnoses were limited to
cases in which direct signs only are noted,
man\ lesions of the alimentary canal would
pass undiscovered. Often more remote phe-
nomena must be considered in the diagnosis,
such as alterations of motility, tonus and peris-

Translations and Abstracts

talsis. All of these manifestations are affected
by spasm. For instance, we are more or less
dependent on changes of contour, spastic in
nature but set up by an intrinsic lesion, such
as spasmodic hour-glass of gastric ulcer or the
spastic deformity of duodenal ulcer. We must
also be able to recognize the spastic deformity
produced by extrinsic lesions remote from the
deformed organ. Such deformity may simulate
that produced either directly or indirectly by
an intrinsic lesion. Thus two types of spasm
are met with ; one may be spoken of as intrin-
sic, the other as extrinsic. The first is often a
help in diagnosis, the latter often a hindrance.
He mentions that four types of gastric ul-
cers may be distinguished at operation.

1. Small mucous erosions and minute, slit-
like ulcers.

2. Penetrating, or perforating ulcers with
relatively deep craters.

3. Perforated ulcers, with or without the
production of accessory pockets.

4. Carcinomatous ulcers.

The first type of ulcer, the small mucous
erosion, offers the greatest difficulty to roent-
genologic detection. It is either a superficial
denudation, or a mere slit in the mucosa in-
capable of holding enough barium to make a
visible projection from the gastric lumen.

The penetrating or perforating ulcer which
has burrowed more or less deeply into the gas-
tric wall, but does not penetrate the peritoneal
coat of the stomach, produces a definite crater
jutting from the lumen of the stomach. The
degree of facility with which this crater can
be seen by the roentgen ray depends more on
the location than on the size of the crater.

The perforated ulcer which has excavated
through the peritoneal coat of the stomach
may, at the time of perforation, become cov-
ered by gastrohepatic omentum, or, if the per-
foration is chronic, it may be protected by
adhesions. In either case the roentgenologic
signs are the same as in the penetrating or per-
forating ulcer before perforation takes place.
The only condition indicating perforation,
therefore, is the depth of the crater. Perfora-
tion of an ulcer with a continuation of the de-
structive process into adjacent tissue results
in the formation of an accessory pocket out-
side the stomach.

Carcinomatous ulcers are not, as a rule, dis-
tinguishable from non-malignant ulcers ; their

roentgenologic signs are very much the same
as those of penetrating and perforated ulcer.

The roentgen ray signs of gastric ulcer may
be divided into three groups.

1. Direct signs (pathognomonic).

a. The niche.

b. The accessory pocket.

2. Indirect signs (but diagnostic).

a. Organic hour-glass stomach.

b. Spastic manifestations.

1. Spasmodic hour-glass stomach.

2. Gastrospasm.

3. Corroborative signs (not diagnostic).

a. Retention from the six-hour meal,

b. Gastric hypotonus.

c. Alterations of peristalsis.

Ulcers not sufficiently extensive to produce
an excavation that can be visualized on the
screen or plate are rarely found at operation;
they are mere mucous erosions or small crev-
ices, and their diagnosis can be made only on
less definite signs such as spasmodic hour-
glass stomach.

Indirect signs (but diagnostic).

1. Organic hour-glass stomach.

2. Spastic manifestations.

a. Spasmodic hour-glass stomach.

b. Gastrospasm.

It has been his experience that an hour-glass
that resists belladonna to the physiologic ef-
fect means a lesion either of the stomach or
duodenum ; and regardless of whether or not
the hour-glass is present at operation, the sur-
geon will find the cause, if he looks for it.

Corrobation signs (not diagnostic).

1. Retention from the six-hour meal.

2. Gastric hypotonus.

3. Alterations of peristalsis.

Six-hour retention — A distinct residue in
the stomach from the six-hour meal is seen in
55 per cent of the gastric ulcer cases. In this
respect gastric ulcer stands a close second to
gastric cancer. The manner in which an ulcer
causes retention is not definitely known in
many cases. While it is easy to understand how
an ulcer located at the pyloric ring may cause
obstruction, it is hard to understand why one
situated remote from the pylorus should do so.
But practically 90 per cent of all gastric ul-
cers occur in the vertical portion of the stom-
ach above the incisura angularis. The reten-
tions which they produce have been assigned
respectively to pylorospasm excited by the ul-

Translations and Abstracts

cer, to impairment of peristalsis, and to liypo-
tonus. A retention alone is not sufficient evi-
dence for the diagnosis of ulcer, since various
causes may operate to produce a six-hour
residue.

Gastric hypotonus — An evident loss of tone
shown by sagging and expansion of the lower
gastric pole is a frequent accompaniment of
ulcer, not only of ulcers causing, obstruction
but also of those situated rather remote from
the pylorus. Hypotonus alone possesses little
significance, for it is an expected finding in
the numerous patients of anteroptotic build ;
but if the hypotonus does not accord with the
habitus of the patient, the possibility of an ul-
cer should be considered.

Abnormalities of peristalsis. — The varia-
tions of peristalsis met with in gastric ulcer
include weak peristalsis, hyperperistalsis, es-
pecially of irregular type, absence of peristal-
sis, especially of irregular type, absence of
peristalsis from the ulcer-bearing area, and
anti-peristalsis. None of these is peculiar to ul-
cer, but all of them are more or less sugges-
tive of a gastric lesion. All lesions of the gas-
tric wall tend to interfere with peristaltic
movement in the area involved. If an ulcer is
located at a point where peristalsis commonly
is visible a noticeable absence appears in the
ulcer ar^a. Anti-peristalsis is occasionally
noted with gastric ulcer, and while it is not
necessarily indicative of ulcer, it generally de-
notes the existence of organic disease either in
the stomach or duodenum, with or without
obstruction.

Carcinomatous ulcer. — The roentgenologic
signs of ulcer differ so much from those of
carcinoma in the larger number of cases that
differentiation requires no effort. A callous
ulcer with a niche, or a perforated ulcer with
pocket formation, has no roentgenologic re-
semblance whatever to a well-developed car-
cinoma. Usually ulcers project from the gas-
tric contour, while in carcinoma the growth
with its resultant irregularity extends into the
gastric lumen. Between the typical ulcer and
the typical carcmoma there is a small per-
centage of cases in which the roentgenologic
differentiation is impossible.

DUODENAL ULCER

He states that the roentgenoligic indications

of duodenal ulcer may be classified as follows:

1. Direct signs.

a. Deformity of the duodenal bulb.

b. Duodenal diverticulum.

2. Indirect signs (diagnostic).

a. Gastric hyperperistalsis.

b. Gastric retention from the six-hour
meal (the combination of hyperperis-
talsis with gastric retention and a
normal gastric outline is diagnostic of
duodenal ulcer with obstruction.)

He enumerates deformities more or less
characteristic of duodenal ulcer as follows :

1. General distortion with the entire contour
of the bulb deformed. This distortion is largely
due to spasm, which is practically always per-
sistent and unvaiying.

2. The niche type in which the excavation
of the ulcer is seen projecting from the bulb.
This type is rare.

3. The incisura type of deformity, either
single or bilateral. The incisura occurs in the
plane of the ulcer, and may be the sole abnor-
mality of contour observed. Unusually narrow
but of variable depth, persistent and perman-
ent as to situation.

4. The diminutive bulb. This is represented
by a small, compact mass of barium in the
cap. It is usually produced by an ulcer sten-
osing the duodenum, so that only the proximal
portion of the bulb is filled.

5. The accessory pocket. This results from
a perforated ulcer which has invaded tissue
outside the duodenum.

6. The diverticulum. A diverticuKim in the
first part of the duodenum is relatively un-
common. It is found near the pylorus, and its
relationship with duodenal ulcer and scars
seems well established.

Cases without ulcer are seen in which the
bulb fails to show a normal contour simply be-
cause of incomplete filling. This is likely to
happen in cases in which the duodenum is
large, but the deception is evidenced by the
varying aspect of the deformity.

In an overwhelming preponderance of cases
a constant deformity means duodenal ulcer.
Such deformity is not absolutely diagnostic,
since distortion of the duodenal shadow may
result, though rarely, from an adhesion-pro-
ducing process in the right upper abdominal
quadrant, or possibly from reflex spasm set up
by lesions outside the duodenum.

Translations and Abstracts

Indirect signs. Hyperperistalsis. Hyperperi-
stalsis consists of three or more waves running
along the stomach at one time. It is seen in a
large proportion of cases and is most exag-
gerated in the obstructive cases, but it occurs
also when there is no obstruction. A character-
istic feature is the regular succession and sym-
metrical correspondence of the waves on both
curvatures. A mere exaggeration of wave
depth should not be confounded with hyper-
peristalsis, since an essential feature of the
latter is an increase in the number of waves,
although they may also show unusual vigor,
Hyperperistalsis is often intermittent in char-
acter, periods of activity alternating with
periods of rest. Of course the phenomenon of
hyperperistalsis is not limited to duodenal ul-
cer, for it may accompany disease of the gall
bladder or appendix or be seen normally in
the hypertonic stomach. Obstructing pyloric
and prepyloric lesions are sometimes attended
by hyperperistalsis, but in such cases the waves
are rarely uniform in depth and sequence, and
they are chiefly on the greater curvature. Oc-
casionally, however, this variety of peristaltic
exaggeration accompanies a perforated duo-
denal ulcer.

A logical result of hypertonus and hyper-
istalsis is hypermotility, provided no marked
obstruction has been produced by the ulcer.
Generally speaking, the initial clearance in
cases of duodenal ulcer may vary from a slight
increase to a profuse flow or it may be abnor-
mally scant with obstruction, and the moderate
intermittent outflow of normal conditions may
be absent. Hypermotility is not peculiar to
duodenal ulcer, for it is a common effect of
gastric cancer, achylia, and the diarrheas. On
the other hand, about 25 per cent of the duo-
denal ulcers are sufficiently obstructive to pro-
duce a six-hour retention in the stomach. If
in addition to the gastric retention there is a
typical gastric hyperperistalsis, the diagnosis
of a duodenal ulcer by x-vay is quite as certain
as a diagnosis on any other evidence that can
be obtained.

Clagett, a. V. The Treatment of Goiter with
Radium. (Illinois M. J., xxxviii. No. 4, p.
318., October, 1920.)

In the author's opinion, the toxic and
Graves' disease forms plus the malignant and
•parenchymatous types are the only varieties

where radium would be beneficial, though ex-
perimental work may show it applicable to a
few of the other forms.

He has treated to date 47 cases of exoph-
thalmic goiter with radium, the patients' ages
ranging from 16 to 74 years. Of these cases
six had already been operated on with recur-
rence of symptoms as bad or worse than be-
fore. Seventeen cases were declined as oper-
able risks. Eight cases had to be rayed the
second time as the dosage was inadequate and
while the patients improved, the first raying
did not give satisfactory results. Two cases
with very bad broken compensation of the
heart have died since treatment from acute
dilatation, one three months after treatment,
the other five and one-half months, though in
both these cases the pulse had showed an aver-
age reduction of thirty beats and the nervous
symptoms were remarkably reduced. In one
case out of five there has been no reduction of
the goiter. The circumference of the neck has
diminished from i^ of an inch to 3^ inches
in the others. One woman's goiter did not de-
crease until thirteen months had elapsed and
then suddenly went down i^ inches in less
than two months.

The exophthalmos has been usually the last
symptom to disappear and has remained in five
of the cases. The pulse beat has been reduced
twenty to fifty beats. Nervous symptoms and
tremors have disappeared entirely and the pa-
tients gained in weight and general well being.
There has been symptomatic cure in all of the
cases treated with the exceptions noted.

The author believes radium should be given
a trial in exophthalmic goiter. Surgery had
not been necessary in a single one of the forty-
seven cases, some of them extending back
nearly three years.

Spencer, Hunter B. Roentgen Therapy.
(Charlotte M. J., Vol. Ixxxi, No. 6, p. 225,
June, 1920.)

The results to be obtained in roentgen ther-
apy are in large measure dependent upon a
careful application of the following principles :

1. Correct diagnosis and knowledge of the
existing pathologic process.

2. Proper selection of cases and recognition
by the roentgenologist of the scope and limita-
tions of this agent.

Translations and Abstracts

3. Knowledge and experience necessary for
the proper administration.

4. Co-operation of the patient and the fam-
ily physician referring the case.

Indications for treatment by the roentgen
ray are — well advanced anemia, organic heart
disease, diabetes mellitus, chronic nephritis,
lung disease and goiter with heart symptoms,
all patients beyond forty in whom there is no
contra-indication. Young women in whom it
would be necessary to do a hysterectomy in
order to remove the growth.

Contra-Indications. — Where there are small
pedunculated tumors, in young women healthy
otherwise, which can be excised without de-
stroying the reproductive powers of the pa-
tient. When tumors are complicated by malig-
nant degeneration or are beginning to become
necrotic. When associated with disease of the
adnexa, or when the patient's condition is such
that the danger of an operation is less than
that of a delay of six or eight weeks which
would be necessary to obtain results.

The experience of the writer and that of
other roentgenologists would suggest the fol-
lowing conclusions:

Deep roentgen therapy stops the hemorrhage
caused by uterine fibroids which is followed by
a gradual disappearance of the tumor.

The treatment of metropathic hemorrhage is
practically always successful.

Uterine hemorrhage occurring at or near
menopause, when not due to malignancy, will
usually disappear quickly.

Roentgen therapy is a most valuable aid to
the gynecologist.

RiNEHART, D. A. Evidence of Gastrointestinal
Disease as Revealed by Roentgenological
Examination of the Digestive Tract. (/.
Arkansas Med. Soc, Vol. xvii. No. 5, p. 107,
October, 1920.)

Roentgenological examination as a means of
diagnosing diseases of the gastrointestinal tract
has a distinct field of usefulness. There is no
other procedure that permits as close and care-
ful observation. It must be emphasized, how-
ever, that only those conditions which produce
permanent change in the stomach or intestine
can positively be detected by its use. Gastric
and duodenal ulcer, and gastric cancer are the
affections of the stomach most readily diag-
nosed by roentgenological examination. The

reliability of the conclusions depends on the
carefulness with which the examination is
made.

Frequently the evidence will be sufficient
for the roentgenologist to make a positive ■
statement; again, the findings may be sugges-
tive but not diagnostic. In the latter instance
he can say that pathology exists at such a place
or he can give his opinion of the cause of the
trouble with the reasons for his belief. In this
instance his diagnosis should be accepted as
merely an expression of his opinion.

Marty, L. A. The Modern Treatment of
Malignancies. (/. Mo. M. Assn., Vol. xvii,
No. 7, p. 271, July, 1920.)

In the year 1918 there were over 65,000
deaths in the United States from cancer. Put
the life of a cancer patient at three years and
you have a total of about 200,000 people suffer-
ing at all times from this disgusting and pain-
ful condition. Are we doing our best for
these cases, or are we in a hopeless state of
mind, feeling that there is no cure? The best
treatment for this class of cases consists of
thorough raying before operation, careful sur-
gery, followed immediately by thorough ray-
ing, and this continued over several months.

Treatment by the ray is always in order,
even in the completely hopeless cases, as much
suffering is relieved, toxemia lessened, and the
patient made more bearable to those about him.

Krupp, D. D. The X-Ray As an Essential
Guide for Producing Artificial Pneumo-
thorax in Advanced Cases of Pulmonary
Tuberculosis. {N. York M. J., October 30,
1920, p. 670.)

In advanced cases of pulmonary tuberculo-
sis, the almost constant harassing cough and
frequent hemorrhages are the most difficult
symptoms to treat.

With the production of an artificial pneumo-
thorax, the affected lung is collapsed and the
annoying symptoms are more or less perman-
ently relieved, certainly to a more marked ex-
tent than by the use of narcotics, and without
their depressing effects. The purpose of the
pneumothorax in these cases is not to produce
a cure, primarily, but to render the patient's
fife more comfortable and possibly increase
his chances for recovery.

Translations and Abstracts

In certain seemingly hopeless cases, the
treatment has caused an apparent arrestment
of the disease in three selected cases cited in
this article. Two of the advanced cases became
ambulatory, after the patients had been bed-
ridden for almost a year. They have shown a
great amount of improvement.

Before a pneumothorax is tried the jf-ray
stands out as the essential guide to the clini-
cian. The fluoroscope is part of the guide. With
the bedside unit, the hand fluoroscope is used
to great advantage. The ;ir-ray plates give the
pathological findings as a permanent record,
while the fluoroscope gives a clue as to the mo-
bility of the chest and the excursion of the
diaphragm of the affected side.

The following points were studied before
pneumothorax was produced: (i) The extent
of the pathology, especially as to cavities. (2)
Will the opposite lung be able to furnish suf-
ficient pulmonary tissue after the affected lung
has been collapsed in front throwing additional
risk to the patient? (3) Pleurisy and ad-
hesions.

Curtis, Arthur H. Radium Treatment in
Gynecology. ( Wisconsin M. J., Vol. xix. No.
4, p. 172, September, 1920.)

The author has used radium for a period of
five years. Each year there has been a relative
decrease in the percentage of major opera-
tions, with a corresponding increase in the pro-
portion of radium cases.

In the cases of uterine carcinoma very few
cures have been obtained. This is ascribed to
the fact that until very recently only those with
bad prognosis have been reserved for exclu-
sive radium treatment, and then, post-operative
radium therapy has not been pushed to the
limit. In spite of these unfavorable statistics,
experience supplies an ever increasing evi-
dence that radium is the best palliative remedy
at our disposal in the management of uterine
cancer and may entirely supplant radical op-
eration in the treatment of this disease.

Except in very few instances of 62 fibroid
cases no attempt has been made to avoid bring-
ing on the menopause. Treatment has consisted
in curettage, with intrauterine application of
50 milligrams for a period of 20 to 24 hours.

Radium makes possible a revival of treat-
ment by myomectomy, favorable cases may
have the larger tumors removed, and there-

after go through pregnancy with the assurance
that radium will obviate the need of a second
operation if other fibroids develop subse-
quently.

In 81 cases of the menopause hemorrhage
was invariably controlled. The technique was
essentially that used for uterine fibroids.

FiscHEL, E. The Use of Radium in Carcinoma
of the Face, Jaws and Oral Cavity. (/. Mo.
M. Assn., Vol. xvii. No. 7, p. 267, July,
1920.)

In the author's experience, radium can be
relied on to heal carcinomatous ulcers of the
face. It is the most efficient method of treat-
ment of carcinoma o fthe eyelids and has re-
placed operative treatment of carcinoma of the
lower lip in a percentage of cases. Tributory
glands should be removed by open operation.

The initial dose of radium should be the
maximum one deemed necessary for the com-
plete destruction of the carcinoma.

The persistent use of radiation after dem-
onstrated failure of the growth to respond fa-
vorably is to be condemned.

Radium has limited use in carcinoma of the
jaws and buccal cavity.

As an adjunct to surgery, radium is of great
value, as its small bulk, diffuse and powerful
action permit it to be implanted in small cav-
ities otherwise inaccessible to any method of
approach.

ScHMiTZ, Henry (Chicago). The Indications
for Radium Therapy in Surgical Conditions
of the Pelvic Organs. {Wisconsin M. J.,
Vol. xix. No. 4, p. 157., September, 1920.)

The biological reaction of cancer cells to
radiation offers the best evidence of the thera-
peutic and curative efficacy of the gamma rays
of radium and the hard roentgen rays. The
efficacy of the treatment must be based on the
demonstrable reduction in the size of the tu-
mor and not on the local changes and improve-
ment in the subjective condition of the patient.

Considering that surgery can remove car-
cinoma tissue but not change the proliferative
activity of the cancer cell and that radium and
roentgen rays will arrest the active mitotic
power of cancer cells but cannot remove them,
it is obvious that in the treatment of cancer
disease we must resort to the combined method
of surgery and ray therapy provided the case

Translations and Abstracts

in question is a clearly operable one. In border-
line and clearly inoperable primary and recur-
rent carcinomata we must confine the treat-
ment solely to ray therapy.

The author reports the clinical results ob-
served in 265 cases. Subtracting 21 clearly
operable cases, there are left 244 that formerly
would have been considered absolutely hope-
less. Thirty-two of the 244 cases have sur-
vived a period of two or more years, during
■ which time they enjoyed perfect health and
working capacity. Eleven of these have suc-
cumbed and 21 are alive.

GiFFiN, C. E. Artificial Menopause Induced by
the X-Ray. {Colorado Med., Vol 17, No. 4,
p. 84, April, 1920.)

This report is based on thirty consecutive
cases selected for ;r-ray treatment between the
year 1914 and 1920. Excessive menstrual flow
constituted the chief indication for treatment
in thirteen cases of this series. Many of them
were cases of menorrhagia of the early meno-
pause. Of these thirteen complete arrest of
hemorrhage and complete suppression of
menses were attained in each instance.

In five cases the reduction of definite
fibroids was the chief indication for treatment.

Combined indications of menorrhagia and
palpable, fibroids were frequently encountered.
There were six such cases in this group, mak-
ing a total of eleven in which fibroids were a
factor. Of these eleven, symptomatic cure was
attained in each instance but three.

Recurrence of flow following primary dis-
charge from treatment occurred in four in-
stances.

Twenty-one of the thirty manifested before
the completion of treatment more or less symp-
tomatology suggestive of the menopause. In
two of these cases the symptoms warranted the
use of ovarian extract.

As to technique: The first dose is adminis-
tered in halves with one week interval; be-
yond that the patient is given the full dose at
one sitting and that is repeated every three
weeks until one period is definitely missed. In
the fibroid cases treatment is continued with a
four weeks interval until the desired result is
obtained. Only two areas are exposed, one
anterior just above the pubes and the other
posterior over the sacrum. The treatment cone
is six inches in diameter and is provided with
a three and one-half mm. aluminum filter with
a wooden compression surface on the opposite
end. A supplementary filter of one and one-
half mm. is always added in treatment of this
class of cases. The exposure time is sixteen
minutes in the anterior and sixteen in the pos-
terior position, with a spark gap of seven and
a half inches with five ma. going through the
tube. The skin-focus distance is always nine
inches.

Age is the essential factor in determining the
number of exposures required for menstrual
suppression. Anatomical conformation is the
other factor. When these are known it is sur-
prising how accurately one can estimate the
probable total time under treatment. Ages
ranged from twenty-eight to fifty-four in this
series. The fewest number of treatments given
was three, in one of the cases close to the time
for the natural menopause. The greatest num-
ber was thirteen, in one of the younger of the
series. The average time under treatment was
twenty-one weeks.

In conclusion the author emphasizes that
careful history, examination and care in selec-
tion can define a large group of pelvic cases
which are better treated by the .sr-ray than by
any other means available. On the other hand,
without the greatest of care, the :r-ray may
easily inflict upon the patient irreparable dis-
aster.

THE AMERICAN JOURNAL
OF ROENTGENOLOGY

Editor, H. M. Imhoden, M.D., 'Hew Tor\

VOL. VIII (new series)

FEBRUARY, i 9 2 i

No. 2

ROENTGENOGRAPHIC STUDIES OF BRONCHIECTASIS AND
LUNG ABSCESS AFTER DIRECT INJECTION OF
BISMUTH MIXTURE THROUGH THE
BRONCHOSCOPE*

By henry L. LYNAH ,M.D.

AND

WILLIAM H. STEWART, M.D.

NEW YORK CITY

T\ R. STEWART'S first experience in
-*-^ outlining the bronchial tree with bis-
muth mixture was purely accidental. In
October, 191 5, while fluoroscoping an old
man with an esophageal obstruction, he ol)-
served some of the bismuth paste passing
from the esophagus directly into the trachea
through a fistulous opening, a portion of the
paste passing down into the lower bronchi. A
roentgenogram was immediately taken. The
patient had three or four coughing spells,
bringing up particles of bismuth paste, and
the following day he seemed none the worse
for his experience. The examination was
repeated about a week later with no ill
effects.

Upon investigation Dr. Stewart found
that a number of similar cases had been re-
ported. It occurred to him at that time that
with proper precautions the injection of
opaque substances into the lung through the
bronchoscope could be safely undertaken.

It was evident that advancement along
this line was slowly being made, for in 191 7

Dr. Sidney Yankauer treated a case of bron-
chiectasis by direct applications of iodine so-
lution to the diseased area through the
bronchoscope. In conjunction with Dr. Willy
Meyer and Doctor Yankauer, this patient
was carefully watched roentgenographically.
Complete recovery occurred.

Between 191 5 and 1920 two cases of
tracheo-esophageal fistula came under obser-
vation in which the main bronchial tree on
both sides was outlined by bismuth paste
escaping from the esophagus through a fis-
tula into the trachea. Early in 1920, the same
phenomena occurred in a case of carcinoma
of the esophagus located just above the arch,
complicated by laryngeal paralysis ; also, in
a patient suffering from carcinoma involving
the laryngopharynx. In both these cases the
bismuth paste entered the trachea beneath the
epiglottis, which was imperfectly closed.
Repeated roentgen examination of these two
patients did not cause any ill effect.

During Dr. Stewart's army experience at
Biltmore, N. C, while examining patients

''Read at the Twenty-first Annual Meeting of The .\merican Roentgen Ray Society, MinneaiX)lis, Minn., Sept. 14-17, 1920.

Roentgenographic Studies of Bronchiectasis and Lung Abscess

suffering from chronic empyema, he fre-
quently injected bismuth mixtures into an
empyemic cavity which had direct communi-
cation through a pleuro-pulmonary fistula
with a branch bronchus. The bismuth mix-
ture would permeate many of the bronchial
branches, be retained long enough to enable
him to obtain satisfactory roentgenograms,
and then would be expectorated. Such an oc-
currence, whether accidental or intentional,
did not seem seriously to disturb the patient.

The experience mentioned above strength-
ened his belief that if accidental entrance
could occur without danger, injections might
be done deliberately and, when combined
with roentgen examination, be used for
diagnostic purposes.

Dr. C. Jackson, of Philadelphia, during
1918, reported a case before the American
Laryngological Association, in which the
main bronchi on the right side were outlined
roentgenographically, after insufflating dry
bismuth through the bronchoscope.

Drs. J. C. Bullowa and C. Gottlieb of New
York, in 1919, reported some experimental
studies on living animals in which the
bronchi had been injected with bismuth and
barium mixtures, roentgenographic oliserva-
tions of which brought out details of the
bronchial tree heretofore never thought pos-
sible. The\- were able to demonstrate a
"wave-like" peristaltic action in the bronchi
and trachea.

So far as we are able to ascertain, it was
not until early in 1920 that any successful
efforts were made to outline roentgenograph-
ically lung cavities after the injection of
opaque substances through the bronschscope.
In May, 1920, Dr. Lynah, of New York,
presented a short preliminary report on the
subject before the American Laryngological
Association; he reported two cases of lung
abscess which had been successfully mapped
out roentgenographically after the injection,
bronchoscopically, of aqueous and oily mix-
tures of bismuth subcarbonate directly into
the area of diseased lung; both these patients
have since been repeatedly examined by the
authors and are included in the five cases re-
ported in this communication.

Case L A man of twenty-six years wha
developed a lung abscess in July, 1919, after
having aspirated sea-water while in swim-
ming. He went out too far, became ex-
hausted and went under ; was hauled out and
by first aid measures soon revived.

One week later he suffered from what was
supposed to be bronchopneumonia ; there

Fig. I. Case i. Lung Abscess One Month after
First Injection. A. Abscess cavity faintly outlined.
B. Remains of bismuth which infiltrated the lung
structure at the time of the first injection.

was a great deal of foul expectoration at
that time.

Within one month the acute symptoms had
subsided, but he continued to expectorate
large quantities of pus. He was sent to New
Platz, N. Y., with a diagnosis of pulmonary
tuberculosis even though no tubercle bacilli
were found in the sputum. There he had
several hemorrhages ; the sputum showed
numerous streptococci, he had fever and
complained of having a "bubbling" sensation
in his right chest. There were several night
sweats. Li February, 1920, the patient con-
sulted Dr. F. W. Corwin of Newark, N. J.,
who referred him to Dr. Lynah for broncho-
scopic examination.

Roentgenograph ic Studies of Bronchiectasis and Lung Abscess

Roentgenographic studies made by Dr.
Corwin showed a definite shadow over the
right lower lobe surrounded by a "pus
soaked" area of infiltrated lung tissue. The
diaphragm was attached and pulled upward.
The roentgenologist in his report stated that
there was a fluid level and gas bubble in an
abscess cavity- ; this however Dr. Lvnah was

on the right side was examined and found,
on coughing, to be free from pus. Pus was
noted coming out of the right middle lobe
branch, which was directly anterior, but,
after this branch was sucked out, and the pa-
tient instructed to cough, no pus was in evi-
dence. The lower lobe branches were filled
with pus; this was removed by suction and

Fig. 2. Case i. Lung Aescess. Immedi.\tely .\fter
Second Injection. A. Ahscess cavity outlined with
bismuth suspended in sweet oil. Small cavities and
bronchial branches in involved area also outlined.
B. Remains of bismuth infiltrated into lung structure
from first injection. C. Main bronchia! liranches.

unable to make out. There was profuse ex-
pectoration of foul smelling pus, and the pa-
tient stated that he had coughed up as much
as would fill two large preserve jars every
twenty-four hours.

He was bronchoscoped after further stud}-
of the roentgenograms. The bronchoscopist
noted a profuse discharge of pus pouring out
of the mouth of the bronchoscope. It was
very foul smelling and Ijlood-tinged. A 7 mm.
bronchoscope was introduced so as to make it
possible to study and explore the lower lobe
branches. After thorough evacuation of the
pus-filled bronchi, the superior lol:e branch

Fig. 3. Case i. Lung Abscess Five AIonths after
Injection. A. Area of diseased lung. B. Small
amount of bismuth still remaining in lung structure
from first injection.

each branch examined in turn and the ])atient
instructed to cough ; by this means the branch
bronchus from which the pus was coming
could be definitely located. The small, but
constant ejection of pus with each cough,
pointed toward the right anterior branch;
this branch was sucked out; however, pus
appeared in the mouth of the bronchus with
each cough in spite of suction. The long
slanting end of the bronchoscope was then
insinuated into this branch. It was now noted
that there were many granulations present
which bled freely. About one ounce of bloody
pus was aspirated at this time into a sterile
bottle and examined by Dr. George S. Dixon
of the New York Eye and Ear Infirmary,

Roentgenographic Studies of Bronchiectasis and Lung Abscess

who reported as follows: "The pus removed
bronchoscopically from the lung abscess of
Mr. F. H. shows a pure culture of Free-
lander bacillus." This was extremely inter-
esting, for the most virulent cases which we
see in the summer caused by swimming about
New York harbor are usually due to the
Freelander bacillus, one of the colon group.
This man had a lung abscess caused by the
inspiration of sea- water about New York-
harbor.

Fig. 4. Case .11. Lung Abscess Before Injection. A.
Abscess cavity showing fluid level with air l)ubl)le
above. B. Pus soaked in filtered area of lung struc-
ture surrounding the a1)scess.

For definite lung mapping the al^scess cav-
ity was injected the following week with a
mixture of bismuth subcarbonate in olive oil
(1-2). The right anterior liranch was in-
jected around a corner by a speciallv made
curved spiral cannule ; 8 c.c. of bismuth mix-
ture was injected slowly so as not to infil-
trate the surrounding lung tissue, and within
five minutes from this time the patient wns
flurorscoped by Dr. Charles Gottlieb,, and
some very interesting observations made. By
fluoroscopy the cavities filled with the opacpte
mixture cotild be distinctly seen. Roentgeno-

grams were also taken in all positions and a
set of stereoscopic plates made. Within ten
minutes the patient was again fluoroscoped
and the bismuth mixture was seen coming
out of the abscess cavity and flowing upward.

He had not coughed up to this time, for he
was breathing as cpiietly as possible. He did
have considerable cough, however, immedi-
ately after the removal of the bronchoscope,
but the fluoroscopic studies made by Drs.
Gottlieb, Corwin and Lynah did not show
anv bismuth in the bronchi ; it was only in the
abscess cavities. While the bismuth was com-
ing out of the abscess cavities into the bron-
chial tree, it was noted that it did not flow
downward but upward, and roentgenograms
taken at the time showed the rniddle and su-
perior lobe Ijranches well outlined by the
opaque mixture while the lower lobe
branches remained free. Shortly after the pa-
tient complained of such bubbling that he
was compelled to cough, and expectorated
about 2 c.c. of the bismuth mixture.

From these observations, Drs. Gottlieb
and Lynah agree that probably there is an-
other mechanism besides cough and the ac-
tic:»n of cilia which causes expulsion of se-
cretions from the tracheo-bronchial tree.

Roentgenograms taken before the injec-
tion did not show a definite outline of the
abscess.

Another injection of bismuth was made
one month later, at which time the roent-
genographic studies were made by Dr. Stew-
art at the Lenox Hill Hospital, who reported
as follows:

"Fluoroscopic and roentgenographic ex-
amination, to ascertain how long the bismuth
would remain in the abscess cavities and also
how long it remained in the lobular structure
into which it had infiltrated, showed that the
bismuth mixture started to make its exit
from the bronchial tree within a short time
after injection. It remained much longer in
the abscess cavities and lobular structures,
but eventually disappeared." Li abscess cav-
ities it may remain from two weeks to two-
months, the shadow growing less opacjue un-
til it finally disappears. This perhaps ac-

Roentgenographic Studies of Bronchiectasis and Lung Abscess

counts for the improvement of the patient
and the diminution of the quantity of pus
expectorated and the disappearance of odor.
The injection of bismuth mixtures, while
done for the purpose of outhning the lung in
order to locate definitely the abscess cavities,
seemed to have a beneficial effect on the pa-
tient. There was no odor to the pus expector-
ated after the second injection; this was so
pronouned that the patient noticed it him-
self and said that he no lonijer had a foul

out toward the periphery, which from the
"pus soaked" spongy lung structure sur-
rounding it appeared much larger than it
really was, and also suggested some pleural
involvement.

The patient had had a tonsillectonn- per-
formed one week before admission bv an ex-
pert laryngologist. At the time of admission
she was expectorating 250 c.c. of pus every
twenty-four hours, and her general condition
was poor.

Fig. 5. Case ii. Lung Abscess Directly after In-
jection. A. Abscess cavity outlined with bismuth
suspended in sweet oil. B. Bismuth outlining small
cavities surrounding large as well as dilated
bronchial branches. C. Bismuth infiltrated into lung
strucUu-e. D. Main lironchial 1>ranches.

breath, for the bad smell and taste had
disappeared.

This case is still under observation.

Case II. A young lady of twenty years
was seen in consultation with Drs. Willy
Meyer and Richard Jordan. The patient was
admitted to the Lenox Hill Hospital and
bronchoscoped shortly thereafter. Roent-
genograms showed what appeared to be a
very large abscess in the left upper lobe well

Fig. 6. Case 11. Lung Aisscess Two Months After
Injection. A. Remains of abscess cavity. B. Small
amount of liismuth still remaining in contracted
cavities. C. Remains of bismuth which infiltrated
lung structure.

Bronchoscopv with a 7 mm. tube showed
pus pouring out of the bronchoscopic tube ;
all the pus having been sucked out, the left
bronchus was entered. There was an edema-
tous bronchial stenosis of the upper lobe ori-
fice with a small opening from which free
pus was expelled with each cough ; in addi-
tion, a membranous placjue was present
which also obstructed drainage from the
upper lobe. The long slanting end of the 7
mm. tube was gently introduced into the

Roentgenographic Studies of Bronchiectasis and Lung Abscess

mouth of the upper lobe orifice separating
the edematous stricture ; the memliranous
plaque was removed by suction. After evacu-
ating as well as possible the upper lobe
branch, the lower lobe branches were exam-
ined but no pus was found in same. The
upper lobe branch was again entered and the
patient instructed to cough ; with each ex[)al-
sive cough there would be a gush of pus from
this branch. The bronchus was a])parentl}'

Fig. 7. Case hi. Bronchiect.\sis Before Injection.
A. Area of diseased lung, with faint evidence of
cavitation. B. Resected ribs. Thickened pleura. C.
Thickened pleura right diaphragm "hooked up"
with adhesions.

draining much more freelv since the edema-
tous stricture had been opened. With a 10
inch vacuum the bronchus was once more as-
pirated and after fifteen minutes the bron-
choscopic tube removed.

The following week the patient had im-
proved somewhat, but the amount of pus had
not greatly decreased.

Dr. Lynah again bronchoscopicallv aspir-
ated the upper lobe branch, and then decided
to inject the bismuth and oil mixture in order
to map out roentgenographically the abscess
cavity. With the curved spiral cannula, 8 c.c.

of bismuth subcarbonate in olive oil was in-
jected too forcibly, so that some of it
squirted out of the spiral and passed down-
ward into the lower lobe branches (leakage
out of the spiral will not occur if the bismuth
is injected slowly, nor will it infiltrate the
lobular structures of the lung). The upper
lobe branches of the lung abscess were also
injected, the bismuth sticking to the wall of
the cavity and thus marking it out. Several
smaller abscesses were now noted, whereas
in the plate before injection the cavity was
interpreted as being very large. The bismuth
mixture did not infiltrate the lobular struc-
tures in the upper lobe. Stereoscopic plates
showed the abscess cavities well anterior and
out toward the periphery, while the mass,
which had leaked down into the lower lobe
branches, was well posterior. A lateral plate
taken at this time showed the relations of the
upper anterior lobe abscess cavity, which was
clearly defined, to the posterior dull opaque
fan-shaped areas due to gravitation into the
dorsal branch.

The bismuth was expelled from the lung,
as in the other patient, within twentv min-
utes after the injection. As some of the bis-
muth had leaked downward into the lower
lobe branches, it was impossible to state
whether or not the bismuth started immedi-
ately to be expelled outward, as in the first
patient, or whether it had gravitated into the
lower lobe branches after it started to be
expelled.

The patient was studied from time to time
with the fluoroscopic screen and further
roentgenograms taken. At the end of one
week there was still bismuth present, both in
the abscess cavity and in the lower lobe of
the lung wdiere no abscess existed ; this
looked somewhat like an abscess cavity, but
was seen roentgenographically as an irregu-
lar area of opaque dullness, and did not have
the metallic luster of the bismuth in the ab-
scess ; this is one of the distinguishing points
between infiltration of bismuth into the lobu-
lar structure of the lung and bismuth in an
abscess cavity.

The patient improved after the injection,

Roentgenographic Studies of Bronchiectasis and Lung Abscess

Fig. 8. Case hi. Bronchiecta.sis Immediately after Fk;. 9. Case hi. Bronchiectasis Six Weeks After

Injection. A. Cavities mapped out with bismuth
suspended in sweet oil. B. Resected ril)s. Thickened
pleura. C. Thickened pleura. Right diaphragm
"hooked up" with adhesions.

Injection. A. Involved area of lung free from
bismuth. B. Resected rilis. Thickened pleura. C.
Thickened pleura, diaphragm caught in mass of
adhesions.

in a manner similar to Case I. The pus de-
creased from her lung, and the amount of
measured sputum in twenty-four hours de-
creased from 250 c.c. to 30 c.c. The odor was
decidedly less and the patient's general health
improved.

Bismuth was still present in the lung when
fluoroscoped ten days after injection, al-
though both shadows were diminishing in
density and the lung abscess was apparently
clearing up.

The patient suffered no discomforts fol-
lowing two injections of bismuth into her
lung. She ate and slept well and had but little
cough. She was bronchoscoped twice after
the injection and we were not able to recover
any of the bismuth by suction, e\'en though
it was still present in the lung. At a later
bronchoscopic examination there was very
little pus recovered by suction and no pus
was expelled from the bronchus when the pa-
tient was instructed to cough.

The patient is still under observation.

Case III. A female, S. M., age twenty-five
years. On March 26, 191 8, she had her ton-
sils and adenoids removed. Ten days follow-
ing the operation the patient began coughing

Fig. 10. Case iv. Bronchiectasis. Before Injection.
A. Area of cavitation. B. Fixed diaphragm with
thickened pleura and bands of adhesions.

up small cjuantities of foul-smelhng sputum,
thick and yellowish in character; the amount
gradually increased and occasionally the
sputum was streaked with blood. There was
pain and soreness in the lower part of the
chest.

She was operated in May, 191 9. Rib re-

Roentgenographic Studies of Bronchiectasis and Lung Abscess

section was performed and the cavity Dakin-
ized; no abscess was found. The following
September the incision was reopened and the
tube placed in the cavity ; there was no drain-
age ; very little improvement occurred. In
November, 191 9, a new incision was made
lower down with resection of a rib; a tube
was left in the cavity, but no drainage oc-
curred. In January, 1920, the incision was
reopened and extended backward. An abscess

pleuritic thickening involving the upper and
middle lobes on the right side; the right
diaphragm was partially fixed with adhe-
sions. In the lower portion of the upper right
and the upper portion of the middle right
lobes there was increased density with here
and there evidence of cavitation.

The patient was bronchoscoped on May
25, 1920. Abundant purulent secretion was
discharging from the upper lobe; 8 c.c. of a

Fig. II. Case iv. Bronchiectasis. Immediateey Af-
ter Injection. A. Area of cavitation outlined with
bismuth suspended in sweet oil. B. Thickened
pleura with adhesions. Right diaphragm "hooked
up" and fixed.

was opened and a tube left in for drainage,
which amounted to four ounces on the first
day and two ounces on the second day. The
discharge gradually decreased, the tube was
removed and the wound healed.

About six weeks later she began coughing
and raising foul-smelling sputum again and
gradually became worse until she was ad-
mitted to the Lenox Hill Hospital on May
17, 1920.

On May 22, 1920, a preliminary fluoro-
scopic combined with stereo-roentgeno-
graphic examination showed evidence of

Fig. 12. Case iv. Bronchiectasis. Four Months
After Injection. A. Area oi cavitation. Small
amount of bismuth still present. B. Some clearing
of lung at right base. Thickened pleura with adhe-
sions. Right diaphragm "hooked up" and fixed.

mixture of bismuth subcarbonate in sterile
olive oil (1-2) was injected in the upper
lobe bronchus ; this was followed by a fluoro-
scopic as well as a stereo-roentgenographic
examination which showed that some of the
bismuth mixture had reached the diseased
area, but not sufficient to map out the cav-
ities satisfactorily.

A roentgen re-examination on June 9th
showed much the same condition as reported
on May 22d. Most of the bismuth had
disappeared.

On July 8th the patient was again broncho-

Roentgenographic Studies of Bronchiectasis and Lung Abscess

scoped, the main upper lobe being injected
as previously. The stereo-roentgenograms,
taken almost immediately after the injection,
showed with excellent detail the numerous
cavities in the lower portion of the upper and
the upper portion of the middle right lobes.

The patient is still under observation and
shows continued improvement.

Case IV. A. L., a young girl twenty vears

Fig. 13. Case v. Lung Ar.scESS. One Month Before
Injection. A. Lung abscess showing fluid level with
air bubble above cavity surrounded by pus-soaked
infiltrated area of lung structure.

old, was admitted to the Lenox Hill Hos-
pital in June, 1920, with the following
history:

Tonsils had been removed two years pre-
viously. Following the operation she was
taken home in an open car, with consider-
able exposure. Pneumonia developed ; the
cough continued, and two weeks later she
began expectorating large quantities of foul
smelling pus. This condition persisted up to
the time of her admission to the hospital.

A preliminary fluoroscopic combined with
stereo-roentgenographic examination, on
June 19, 1920, showed marked pleuritic

thickening over the middle and lower right
lobe ; the right diaphragm was "hooked up"
with adhesions and there was considerable
increased density in the middle and lower
right with evidence of cavitation, especiallv
in the lower lobe.

June 20, 1920, bronchoscopic examination
showed pus coming from the middle and
lower right lobes ; none from the upper. A
mixture of 8 c.c. of bismuth subcarbonate in
sterilized olive oil was injected into the
bronchi of the middle and lower right.

Roentgen examination, made as soon as
possible after the injection, showed the
iM'onchi within the diseased area well out-
lined, with numerous cavities clearly demon-
strated.

When the patient entered the hospital she
expectorated 300 to 500 c.c. per day. Since
the injection gradual improvement has oc-
curred with marked diminution in the
(|uantity of expectoration.

The patient is still under observation.

Case V. E. E., male, age twenty-four
years, entered the Lenox Hill Hospital on
June 18, 1920, with following history:

Had tonsils removed June 5, 1920; six
days later developed a cough which became
productive on about the ninth day. On ad-
mittance his chief complaint was cough with
expectoration, and pain in the joints.

June 23, 1920, a preliminary roentgen ex-
amination was made which revealed a dense
triangular area in the lower portion of the
upper right lobe ; in the center of this pus-
soaked, spongy area of infiltrated lung tissue,
a fluid level with an air bubble above could
be made out, indicating a large abscess.

On June 29th he was bronchoscoped, a
9 mm. tube being used. Pus was seen coming
from the right upper lobe bronchus only.
About 10 c.c. of bismuth subcarbonate in
sterilized olive oil (1-2) was injected into
the right upper bronchus; this was followed
by roentgen examination which showed the
lower bronchus outlined by the injection,
very little if any having passed into the dis-
eased area.

Roentgenographic Studies of Bronchiectasis and Lung Abscess

He was again bronchoscoped on July 8th.
Pus was still obtained from the right upper
bronchus which was again injected with l)is-
nnith suspension. Fluoroscopy and stereo-
roentgenograms showed bismuth outlining
the numerous cavities; some of the mixture
had infiltrated into the lobular structures
well out toward the periphery of the upper
portion of the dense area.

The quantity of sputa gradualh- dimin-

2. The injection of an opaque substance
into the lung of the living patient will open
an enormous field of usefulness in the study
of cough, the expulsion of substances from
the lung, and lung drainage. It will also aid
in localizing bronchial strictures in the same
manner as in the esophagus. Furthermore,
it will be of the greatest aid to the thoracic
surgeon by mapping out the abscess cavity in
the respective lobe of the lung.

Fig. 14. Case v. Lung AnscEss. Directly After Ix-
jECTiox. A. Lung abscess mapped out with bismuth
subcarbonate suspended in sweet oil. B. Bismuth
infiltrated into limti structure.

ished until July 19th, when it had practically
disappeared and the arthritic symptoms had
greatly improved.

A stereo-roentgenographic re-examination
on July 26th showed gradual disappearance
of the bismuth except where it had pene-
trated the lobular structures.

The patient is still under observation.

SUMMARY

I. Bismuth mixtures can be injected into
the bronchi and lungs of a living patient
without danger.

Fig. 15. Case v. Lung Abscess. Three Weeks After
IxjECTiox. A. Remains of cavitj'. B. Bismuth infil-
trated into lung structure. C. Dilated right bronchus.

3. A definite lung abscess cavity is seldom
seen bronchoscopically. Pus is usually seen
coming from a branch bronchus, although
the abscess may be well around the corner,
and not in that portion of the lung from
which the pus is oozing. An injection of bis-
muth mixture or some other opaque mixture
will "clear up" this error.

4. Bismuth, when it enters the abscess
cavity, is recognized by its metallic luster,
whereas when it is in the lobular lung struc-
ture, it is discerned as a dull opaque area.
Pus diffuses and soaks the lobular structure
in a manner similar to bismuth : this often

Roentgenographic Studies of Bronchiectasis and Lung Abscess

makes the involved area appear many times
larger than it really is.

5. The bismuth mixture injected in these
patients was 8 c.c. of bismuth subcarbonate
in pure olive oil (1-2). The mixture is
rendered sterile by boiling before injection.

6. The injection should be made slowly
and not with a "squirt," or else the roent-
genographic observations may be spoiled by
bismuth soaking the lung structure surround-
ing the diseased area.

7. It seems from these preliminarv studies
that cough and action of cilia are not the
only means of expelling secretions.

8. While bismuth mixtures were origin-
ally injected for the purpose of lung mapping
in cases of lung abscess cavities, they seem
to have been of therapeutic benefit to the five
patients upon whom they were tried. So far
the procedure has done no harm.

9. While the fluoroscopic examination is
important, stereo-roentgenographic examina-
tion is the best means of localizing the
cavitations.

10. Experience has shown that the roent-
gen examination should be made almost im-
mediately after the removal of the broncho-
scope, otherwise the patient, in a fit of
coughing, will remove much of the bismuth
from the involved lung.

DISCUSSION

Dr. David R. Bowen. In the slide that was
shown of Dr. Jackson's case the remarkable
thing was that this plate was made on the
fluoroscope with double screen. We hurried the
patient to the stereoscope, and there was noth-
ing there, although it could not have been more
than fifteen minutes.

Dr. W. F. Manges. I should like to ask Dr.
Stewart why he uses so much bismuth, why
the mixture is so concentrated. This is a rather
big field for study, and I wonder if it would
not be well to advise a bit of caution. It seems
to me that one should first be sure that he has
the proper facilities for taking care of emer-
gencies. Unless one has the association of a
competent bronchoscopist, the procedure had
better not be started. I think those of us who

are in laboratories where there are efficient
bronchoscopists, where there is every means
for taking care of emergencies, ought to do
everything we can to continue and work with
Dr. Stewart alone these lines, and see if the
end results are going to be right.

It seems to me that since a foreign body in
the lung tissue must be removed sooner or
later, for eventually the foreign body in the
lung is apt to set up a suppurating process, I
do not see why bismuth should not act as a
foreign body in the lung tissue that has not
been previously walled off by fibrous tissue —
why it should not become a foreign body be-
cause of its metallic properties.

Dr. W. C. Hill. I should like to ask Dr.
Stewart whether, in any of these cases where
the bismuth was retained a month, there were
any symptoms of bismuth poison, not nitrate
poisoning, but bismuth poisoning. I know of
two deaths from bismuth poisoning and I saw
another case, a child, who was closely follow-
ing the course of the others when I saw it, and
advised evacuation of the bismuth.

Dr. G. E. Pfahler. I would like U) compli-
ment Dr. Stewart on his brilliant work, as well
as the daring which led him to undertake it,
but I would like to ask whether there is any
benefit to the patient, or whether the benefits
are purely diagnostic — whether the method has
a therapeutic value to the patient other than
simply to outline the abscess cavity for the
benefit of the surgeon. We must, after all, con-
sider how much good this is going to do the
patient.

Dr. p. M. Hickey. I, too, would like to
compliment Dr. Stewart on this pioneer work,
and would like to take up the cudgel in its be-
half. It is quite possible for a foreign body to
remain in the lung without setting up irrita-
tion. I have two plates in the exhibit room —
one a child who had a peanut in the lung for
five weeks, and the other for two weeks. When
I introduced the bronchoscope, there was no
appearance of secretion. The bronchus was
perfectly clear.

During this discussion, I have been thinking
over some work I knew about some years ago,
when a friend of mine injected the trachea and
bronchi daily with a laryngeal syringe for

Roentgenographic Studies of Bronchiectasis and Lung Abscess

chronic cough. The solution he used was ohve
oil and guaiacol. He used it in considerable
quantities, and it seemed to be a soothing
application.

If the bronchoscopy is done by a competent
man, the injection of a small amount of sterile
solution in the bronchus, I believe, can have no
deleterious effects. It is certainly a very bril-
liant thing to be able to map out the bronchi
in the way it has been done. It would, of
course, be easier to collapse the lung and get
rid of the abscess in that way, but this new
method is important in that one is able to
demonstrate in these cases the exact extent of
the pathology present. It seems to me that,
from a theoretical standpoint, there can be no
danger to the patient, inasmuch as you use only
a local anesthetic.

Dr. F. F. Borzell. It seems to me that there
is considerable weight to Dr. Manges' state-
ments. It might be true that when the bismuth
is first injected, it is sterile ; and I do not doubt
that many of our foreign bodies which are in-
haled are sterile at the time of inhalation ; but
with the bronchioles being constantly sub-
jected to infection from without no foreign
body would remain in the bronchiole for any
length of time without becoming infected,
resulting in the varied pathology one sees with
any other infected foreign body in the
bronchial system.

Dr. James T. Case. Are there any further
discussions? If not, I should like to speak of
'my own experience in this matter. I have
known of two deaths following the actual in-
spiration of barium-mixed food into the
larynx, in one case the mixture being only bar-
ium and water. This was a case of carcinoma
of the esophagus. One case I have especially
in mind was one in which Dr. L. L. McArthur
injected a bronchial cyst which had a pharyn-
geal opening. In the injection, a fairly large
quantity of the bismuth mixture was used, the
injection being done about five o'clock in the
afternoon. During the night, the patient had a
sudden fit of coughing. The next morning, she
was brought to the A--ray room to see what had
happened. The entire bronchial tree was dis-
tinctly filled with bismuth. Following this, the
patient had a most violent case of multiple

abscess of the lung, and it was a miracle that
she lived through it ; but she finally made a
complete recovery.

Dr. W. H. Stewart. I expected, of course,
a certain amount of criticism, and am very glad
to have had the discussion entered into as it
was. I always have a great regard for the
opinion of Dr. Manges, as I believe he is one
of the most conservative men in this particular
line, and I have to voice his ideas, that it must
not be taken up promiscuously, that the work
must be done by an expert bronchoscopist, but
it can be done absolutely without danger. It is
really remarkable, gentlemen, that every one
of the five cases reported this evening, wrote
Dr. Lynali and asked for a re-examination,
because they had received so much benefit
from the bismuth injection. There is no ques-
tion of the therapeutic value of this procedure
to the patient. In one case the amount of ex-
pectoration was reduced from 500 c.c. in
twenty-four hours to 30 c.c. in twenty-four
hours. Whether or not a cure will be eft'ected,
we are unable to say at the present time, nor
are we able to say whether the bismuth which
infiltrated the lung structures will cause any
further trouble. It has not up to the present ;
it is gradually disappearing and does not seem
to act as a foreign body. I believe it will gradu-
ally disappear without any inconvenience. We
have observed these cases for only six months ;
all are under close observation, however, and
will be watched carefully.

In regard to the opaque solution — Dr. Lynah
tried thorium and other mixtures of like char-
acter. He found that bismuth subcarbonate and
sweet-oil was the one non-irritating mixtvire ;
it does not seem to trouble the patient in the
least.

Dr. Hill asked regarding bismuth poisoning.
I can emphatically state that never, in any way,
has there been any evidence whatsoever of
bismuth poisoning. As stated before, the pa-
tients were all benefited to such an extent that
each and every one wrote a letter asking to
come back to the Hospital for another
injection.

With regard to the benefit to the patient, as
asked by Dr. P fabler, there seemed first to be
the diagnostic element, and second, the thera-
peutic effect, Dr, Lynah questions in his own
mind whether the benefit is due to the bismuth

Bucky Diaphragm Principle in Spine Radiography

in the lung or whether to the fact that the
bronchoscopy opened up the bronchi and al-
lowed a free drainage of the lung. At the pres-
ent time I believe both elements enter into it.
Dr. Borzell, I think I have answered in re-
gard to the retention.

With regard to Dr. Case's experience, it is
impossible for me to say why this case should

have such untoward effects. It may be that the
injection was not made with the same precau-
tions which Dr. Lynah uses in making his in-
jections.

I am very sorry that Dr. L}nah is not here.
He is a brilliant speaker, and would be better
able to defend his position than I, who only
take up the ji'-ray side of the question.

THE BUCKY DIAPHRAGM PRINCIPLE APPLIED TO
RADIOGRAPHY OF THE SPINE'

By H. E. potter, M.D.

CHICAGO, ILLIXOIS

mcnt of time in grid movement has pre-
vented the extremely rapid exposures desired
in working with the moving viscera. We
mav sav that since Februarv of this vear all

1\/f Y object in presenting this short paper
■^ -*■ on radiography of the spine is not for
the sake of reviewing the well-known path-
ologic conditions in w^hich .r-rays have
proven of diagnostic value, or of calling at-
tention to their differential features, but to
set before you for your criticism a series of
technical results made by a method with
which you are familiar in theory but which,
as far as I am able to learn, has not been used
in a practical routine manner outside of our
laboratory.

Those who are not familiar with the work
wc have been trying to do in adapting the
Bucky diaphragm principle to practical ra-
diography may be referred to the article pub-
lished in the June number of our Jourxal.
This takes up the construction of a parallel
grid which moves between patient and plate
during an exposure and serves to absorb a
large number of the obnoxious scattered
rays, while its simple movement serves to
neutralize its own shadow. Attention was
called to the larger number of scattered rays
present in penetrating the deeper portions of
the body, such as the abdominal or pelvic re-
gion. For this reason, in combination with
one other, we have chosen to exemplify first
the results obtainable in radiography of the
spine. The other reason is that with crude
apparatus of our own construction the ele-

*Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn., Sept. U-IT, 1920.

Fig.

I. Fractured Lamixa of First Lumbar.
PRESSiox OF Second.

Com-

Bucky Diaphragm Principle in Spine Radiography

our spine cases have been handled by this
method, and in the last months all of the kid-
ney and gall-bladder cases.

The net results of the method are to give
us plates which show a heightened contrast
between bony and other structures, and a
greater clearness in the more delicate struc-
tures of the spine complex in as large a sec-
tion of the spine as is desired. It necessarily

plates. We believe that shortly the Bucky
diaphragm method will form a basis for ob-
taining results on the spine which are en-
tirely comparable to those obtained on the
extremities, and at this time we wish to
record systematically a number of respects
in which the method has materially helped
us in our diagnostic efforts:

I. In the recognition of tuberculosis and

Fig. 2. A Few Fractured Spines Showing Large Scope of Exploration without Sacrifice

OF Radiographic Quality.

follows that the gross lesions can be studied
more comprehensively and the minor or be-
ginning lesions brought to light with greater
certainty. In the latter years we have all be-
come used to seeing the most critical radio-
graphs of the extremity bones, and we shall
all admit, when we stop to think, that in
the most important spine cases the diagno-
sis is often made possible by the last lo or
20 per cent in the technical excellence of the

metastatic carcinoma. Early tuberculosis
and beginning metastasis are deservedly sub-
jects which give the roentgenologist great
concern on account of their clinical signifi-
cance and general difficulty of recognition.
The large comprehensive plates have more
than once yielded unexpected information a
few inches higher or lower than was clini-
cally suspected. Slight or suspicious changes
in any anterior portion of the vertebral body

Bucky Diaphragm Principle in Spine Radiography

have been followed up by plates projected
oblicjuely or laterally so as to bring the sus-
picious point into profile, with the result that
the suspicion was turned into a diagnosis.

2. This ability to obtain critical plates in
oblique or lateral positions has many times
resulted in the graphic measurement of
slight impactions to the bodies of vertebrae

brae. Vertebrae lying above the diaphrag-
matic line have a peculiar anatomic relation-
ship, in that on either side the air-filled lungs
easily transmit rays which flood into the
central plate area before the denser spinal
structures have been fully recorded. It was
one of our surprises to see how the plates
with the Bucky apparatus prevented this

Fig. 3. Deep Osseous Radiography for Disease.
A. Tuberculosis with Bony Reaction. B. Typhoid Spine, after eight months. C. Metastatic carcinoma of

prostatic origin. Hypertrophic Arthritis.

where such could scarcely be known to exist
by any simple or stereoscopic series made
from in front. The general value of lateral
spines has been brought out in this Society
by Hickey and others. The Bucky dia-
phragm method offers us the easiest means
of obtaining results in this most difficult
technique.

3. This filtering method makes possible
much more critical study of antero-posterior
plates of the middle and lower dorsal verte-

source of fog and gave us the same clean
results obtainable elsewhere.

4. In the study of the pelvic structures
the method has been gratifying on account
of our ability to obtain a comprehensive
plate of the whole pelvis without losing the
details about either the hip-joints or the
sacro-iliac region. Fractures of one portion
of the pelvic ring are so often associated
with a second fracture elsewhere in the pel-
vis that comprehensive plates should be re-

Bucky Diaphragm Principle in Spine Radiography

lied upon for the whole of the truth, particu-
larly if radiographic detail can thus be
preserved.

5. In cases of old minor injuries to the
lumbar spine, associated with traumatic or
other arthritis, or with callus formation.
when structures of the pedicle and not the
bodies have been fractured, etc., nothing
short of the most excellent plates by this or
any other method can lead one to a justifi-
able diagnosis, fulh- protected and set aside

a large focus tube is used the hard lines lose
somewhat of their sharpness. This disad-
vantage can be corrected somewhat by the
use of fine focus Coolidge tubes, increasing
the tube distance and using a grid of greater
fineness and less depth.

DISCUSSION

Dr. B. C. Darling. The opportunity to
make the large-sized plate seems to me is a
distinct advantage. There has always been a

Fjg. 4. A Few Lateral, Semi-Lateral or Near-Lateral Spines.
A. Lateral from Figure 3-A. B. Normal lateral for scope. C. True lateral in compression fracture.

from the anatomic architectural peculiarities
common in the lower spine.

These in brief are the advantages which
we believe have been observable in our
routine work. There is one disadvantage
which can be seen in an inspection of any
series of our plates. The osseous structures
are slightly enlarged because of the increased
distance between patient and plate, and when

limitation, for in order to get satisfactory
plates, we had to use a small cone. By this
method, we will be able to use more 11 x 14
and 14 X 17 plates, and we will get much finer
detail by this method. The hardest thing to get
is thus made easier, and in this way our diag-
nostic ability will be improved.

I had the pleasure of seeing this apparatus in
Dr. Potter's office the other day, and he cer-

Left Half of Abdomen Diagnosed by Pneumoperitoneum

tainly has something worth while. He has
something that, if mechanically perfected, will
be of great value.

Dr. p. M. Hickey. Last summer I had the
pleasure of visiting Dr. Potter's office, and
seeing a demonstration of how this diaphragm
works, and the plates which he has I have
never seen equaled, either in number or quality.
It is a wonderful thing that roentgenography
of these parts of the body, which heretofore
has been so difficult, can be brought out with
such a wealth of detail.

Dr. Isaac Gerber. I would like to know

whether Dr. Potter has found that the use of
this diaphragm was interfered with at all in
double screen and film work, or whether all
of his exposures are made on straight plates
or films.

Dr. H. E. Potter (Closing). The first expo-
sures were made with plates entirely, and this
seemed pretty hard on the thirty milliampere
Coolidge tubes, so all the rest of the exposures
have been made with double screen film, which
is very much easier on the tube and simpler in
technique. The double screen greatly aids
instead of interferes with the method.

PNEUMOPERITONEUM AS AN AID IN THE DIFFERENTIAL

DIAGNOSIS OF DISEASES OF THE LEFT HALF

OF THE ABDOMEN ^=

By a. F. TYLER, B. Sc, M.D., F. A. C. P.

OMAHA, NEBRASKA

O INCE this paper is part of a symposium
^ on the use of gas in the peritoneal cav-
ity for diagnostic purposes, I am definitely
limited in my discussion to the use of this
method as an aid in the diagnosis of diseases
of the left half of the abdomen.

Because of the fact that many cases com-
plaining of vague symptoms on the left half
of the abdomen present themselves for ex-
amination, it occurred to me when I began
using this method of diagnosis that such
aid might be of considerable use in clearing
up this type of obscure cases, so that it has
been my custom when I am unable definitely
to locate pathology in the left half of the
abdomen by the usual physical examination
and the opaque meal examination of the
gastro-intestinal tract, to employ pneumo-
peritoneum as a further method of investi-
gation. We have been happily rewarded in
many of these obscure cases, a few of wdiich
will be mentioned in the body of the present
paper.

*Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn., Sept. 14-17, 1920.

In reviewing my experience with pneumo-
peritoneum it has occurred to me that the
greatest percentage of cases in which it has
been definitely helpful have been those with
some form of left-sided patholog}^ In order
that we may lay proper foundation for path-
ological discussion, let us review for a mo-
ment the anatomy of the left half of the ab-
domen in relationship to findings demon-
strable by penumoperitoneum. When the ab-
domen is filled with gas, it is possible to see
clearly the outline of the diaphragm
stretched across from the center to the left
ribs and above this, of course, the lung in
the chest cavity. Below it can easily be dem-
onstrated that the spleen, and in many cases
even the pedicle of the spleen, can be readily
seen. Near the central portion of the left
half of the abdomen can be seen the left kid-
ney in toto. In some cases the left lobe of the
liver can be visualized together with the tail
of the pancreas. In other cases one will see a
band extending across from the left parietal

Left Half of Abdomen Diagnosed by Pneumoperitoneum

wall of the abdomen over toward the center,
which is only the mesenteric attachment of
the splenic flexure of the colon. One must be
careful that this is not interpreted as patho-
logical. Having these essential anatomical
points in mind, it is then not difficult to de-
termine what is pathological.

Patients frequently present themselves for
examination complaining chiefly of colic in
the left side which on investigation may

nephrosis, new growth, supernumerary kid-
ney, ureteral plug or kink. In the spleen, we
must differentiate between the different leu-
kemias, enlargement from malaria, syphilis,
hemolytic icterus or Banti's disease and peri-
splenic adhesions. In the pancreas we must
differentiate between cyst and pancreatitis.
The left lobe of the liver must be differen-
tiated from the pancreas, the spleen and the
kidnev. We mav further find adhesions of

Fig. I. Case No. 13965. — L.\rge Retroperitoneal
Tumor with Kidney Showing Above and Dis-
tinct FROM THE Mass. Proven at operation to be
sarcoma.

prove to be renal or ureteral in type or per-
haps colonic in origin. They will complain of
an indefinite dragging or pulling sensation
which is worse in the erect position and is
relieved by lying on the back or on the left
side. We are compelled in these cases then, to
differentiate between diseases of the kidney,
of the left colon, of the spleen, of the pan-
creas, of the left lobe of the liver and retro-
peritoneal new growth. In the colon we must
differentiate between spastic or ulcerative
colitis, adhesions, diverticula and new
growths. In the kidney, we must differentiate
between stone, pyelitis, tuberculosis, hydro-

FiG. 2. Case No. 13965. — An Oblique View of the
Same Patient as Shown in Figure i, Showing
THE Kidney Separate from the Mass.

the various organs one to the other or to the
parietal peritoneum. We may, in some cases,
find a retroperitoneal new growth, such as a
large retroperitoneal sarcoma recently dem-
onstrated.

In speaking of the differential diagnosis
in these various conditions, it is my thought
that this differential diagnosis cannot be
complete in any case without thorough phy-
sical examination, including the x-ray exam-
ination and the different laboratory tests, to-
gether with catheterization of the ureter and
other methods usually employed for elimin-
ating or confirming diagnosis; so that in my

Left Half of Abdomen Diagnosed by Pneumoperitoneum

presentation of this subject, I take it for
granted that all of these different methods
are being employed along with pneumoperi-
toneum, as Case and others have shown that
diverticula of the left half of the colon are
not infrequent and when carefully searched
for are c[uite readily demonstrated by the
usual opac[ue meal and similar methods of
examining the gastro-intestinal tract. As a
rule the spastic or ulcerative colon can be

into the peritoneal cavity, as well as new
growths involving the kidney, or retroperi-
toneal space. Different types of enlarged
spleen can be demonstrated by pneumoperi-
toneum, but must be differentiated by the
complete blood count and different labora-
tory methods. Cysts of the pancreas can be
positively proved by pneumoperitoneum bet-
ter than by any other method. Adhesions to
the various organs can be actually visualized

Fig. 3. Case No. 13285. — A Dense Band of Adhe-
sions Stretched across from the Colon to the
Left Side of the Parietal Peritoneum. On inspi-
ration, the spleen presses down against the hand, as
shown in the cut. On expiration the spleen moves
away from it.

demonstrated roentgenologically in the same
manner. New growths in the left half of the
colon are readily demonstrated by the opac{ue
method. Stone in the left kidney is demon-
strated without the use of pneumoperito-
neum ; but in some cases there is a Cjuestion
as to whether the shadow is really a kidney
stone or a calcareous mesenteric gland, and
pneumoperitoneum will help us to dift'eren-
tiate, especially when catheterization of the
ureter is impossible. Hydronephrosis can
readily be demonstrated by injection of gas

Fig. 4. Case No. 12880. — Large Cystic Ovary,
Accompanied by Multiple Fibroid Tumors of the
L^terus. Proven ,\t Operation.

by the injection of gas into the peritoneal
cavity, clearing up many obscure cases.

CASES

Case 13844-. INIrs J. M. B., age thirty-
three years.

History. — When the patient was twelve
years old she had an attack of bilious fever
with jaundice. For seven years she has had
pain in the left upper quadrant of the abdo-
men, which radiates to the back and varies in
intensity. She has abdominal distension with
gaseous eructations, nausea, but no vomiting
and no jaundice.

Left Half of Abdomen Diagnosed by Pneumoperitoneum

Physical Exaiiiinafion. — There was a pal-
pable tender mass in the left upper quadrant
of the abdomen and slight tenderness in the
right upper quadrant.

Roentgen Examination. — This revealed a
large soft tissue shadow in the left upper
quadrant which has the contour of a kidney.
Pneumoperitoneum proves that the shadow
is the left kidney, the spleen being normal in
size. There are perisplenic adhesions from
the spleen to the diaphragm. The stomach is
normal in shape, size and position, empty
in six hours. The duodenum is normal. The
appendix has been previously removed. The
cecum and colon are normal in contour, low,
but freely movable.

Diagnosis. — Enlarged left kidney; peri-
splenic adhesions.

Case 13440: J\Iiss A. D., age thirty-four
years.

History. — For five years patient has been
having attacks of abdominal distress, which
usually last several weeks, characterized by
a feeling of fullness or pressure in the epi-
gastrium and in the left side of the abdomen,
extending into the back.

Physical Examination revealed a definite
tenderness in the lower right quadrant of the
abdomen. Examination otherwise negative.

Roentgen Examination. — The stomach is
normal in shape, size and position ; empty in
six hours. The duodenum shows spasm. The
appendix has been previously removed. The
cecum and colon are normal in contour and
freely movable.

Pneumoperitoneum shows adhesions ex-
tending from the left parietal peritoneum
across to the greater curv-ature of the stom-
ach.

Diagnosis. — Perigastric adhesions involv-
ing the greater curvature.

Case 12846: Miss J. G., age twenty-four
years.

History. — Patient complains of splashing
in the stomach accompanied by pain and
vomiting. She was examined by me in
March, 1918, at which time a diagnosis of
chronic appendicitis was made. This was fol-

lowed immediately by an appendectomy. In
July, 1 91 8, a gastro-enterostomy was done.
She has not been well since.

Physical Examination. — Patient was of
the enteroptotic type. There was dullness in
both apices of the lungs with rales in the left
apex and left axilla.

Roentgen Examination shows the opaque
meal passing through the gastro-enterostomy
opening. The chest shows increase in both
hila. Peri-bronchial infiltration well up in
both apices. JMultiple areas of consolidation
in the left upper lobe.

Pneumoperitoneum shows a few adhe-
sions to the abdominal wall at the scar. The
shadows of both kidneys are visible. Folds of
soft spleen, the uterus, tubes and ovaries are
demonstrated.

Diagnosis. — Pulmonary tuberculosis. Ab-
dominal adhesions.

Case 12355: j\Irs. G. H., age forty-five
years.

History. — Patient has been constipated
for many years. For the past ten years she
has had a tender point a little to the right
and below the umbilicus. She now has con-
stant pain which radiates to the right thigh
and to the back, but it is never very severe.

Physical Examination. — Negative except
for general abdominal tenderness with the
maximum point one inch to the right of the
umbilicus.

Roentgen E.vamination.' — The stomach is
normal in shape, size and position ; eight
ounce residue at five hours. The duodenum is
normal. The cecum is not freely movable.
The colon is normal and freely movable. The
appendix is not visualized.

Pneumoperitoneum shows adhesions ex-
tending from the left side of the colon near
the splenic flexure over to the parietal peri-
toneum near the costal arch.

Case 13346'. Mrs. F. H., age twenty-nine
years.

History. — One year ago the patient had
her appendix removed. Two years prior to
her operation she had indigestion and pain

Left Half of Abdomen Diagnosed by Pneumoperitoneum

in the epigastrium with occasional vomiting.
Since the operation, she has had a dull gnaw-
ing pain in the right upper quadrant. This
pain is relieved by lying down. There is a
feeling of fullness after meals.

Physical Examinaiion shows marked ten-
derness in the right u|)per quadrant of the
abdomen.

Roentgen Examination. — Filling defect

creased until the time of the examination. At
the time of the examination the enlargement
extended up under the right ribs.

Physical Findings revealed a large uterus
which nearly filled the entire abdomen. The
mass was smooth except for several nodules
on the upper anterior aspect.

Pneinnoperitoneuin shows a fibroid tumor
of the uterus plus pregnancy. One month

Fig. 5. Case No. 12846. — Spleen Showing Typical
Folds Frequently Noticed at Postmortem Ex-
amination IN A Soft Flabby Spleen.

on the lesser curve near the pylorus, prob-
ably spasm, no tender point ; empty in five
hours. The duodenum is normal.

Pneumoperitoneum shows a band of ad-
hesions to the colon near the splenic flexure,
against which the spleen is pressed on deep
inspiration. A band of adhesions from the
scar in the right iliac fossa to the head of the
cecum is also demonstrated.

Case 12973: Mrs. T. E. A., age forty-one
years.

History. — Three months previous to ex-
amination the patient noticed that the abdo-
men was growing larger. This gradually in-

FiG. 6. Case No. 133440. — Arrows Point to Bands
OF Adhesions Extending across from the Greater
Curvature of the Stomach to the Left Parietal
Peritoneum.

later: Fetus is not visualized, but fluid in the
uterus is demonstrated.

Case: Miss M. E. Age nineteen years.

History. — About two years ago patient
began to have pain and swelling in feet and
arms which was worse at night. She had a
cough and pain in the chest, and night sweats
once in a while. She was so weak at times
that she could not walk upstairs.

Roentgen Examination. — Peribronchial
infiltration well out in both lungs. Both sides
of the diaphragm move freely.

Pneumoperitoneum shows the liver, both
kidneys, tubes, uterus and left ovary normal

Left Half of Abdomen Diagnosed by Pneumoperitoneum

in size and position. No abdominal adhe-
sions. Cyst of the right ovary.
Diagnosis. — Cystic right ovary.

Case: Mr. J. C, age forty-nine years.

History. — About one year ago patient felt
pain in left side and afterwards, due to curi-
osity, v^ould feel his side and had pain on
pressure. Later he felt a mass in the left side,
which has continued to enlarge until its con-
tour can be seen on inspection.

Physical Examination. — A large mass in
the left upper quadrant of the abdomen
which is painful to pressure and movable.
Large tumor in the left side of the abdomen,
clinically hydronephrosis. Large smooth
mass extending beyond the median line to the
right and continuous with the kidney
shadow.

Pneumoperitoneum. — Movement of fluid
in the sac visualized. Stone in left ureter just
back of the l)ladder. Probably hydro-
nephrosis.

Diagnosis. — Ureteral calculus.

Operati-c'e Findings. — Large retroperi-
toneal sac containing urine, attached to the
lower pole of the left kidney which lay to
the right of the median line. L^reter not con-
nected to sac.

Case: Mr. J. H., age twenty- four years.

History. — Patient first noticed swelling of
the abdomen accompanied by pain in the
small of the back and around the umbilicus,
especially at night when lying on his side.
During the past week he has had a slight
cough and two profuse night sweats.

Physical Examination. — Dullness of both
apices posteriorly from the scapula down.
Abdominal distention and umbilical hernia
present.

Roentgen Examination. — A small amount
of fluid in the left pleural cavity posteriorly.

Pneumoperitoneum showed adhesive peri-
tonitis with ascites, probably tuberculous.
Only a small amount of gas could be injected
as the needle entered a pocket. The patient
complained of pain when very little gas had
been injected.

Diagnosis. — Tubercular peritonitis.

Case: Mr. P. S., age sixty-eight years.

History. — The patient had the prostate
gland removed in 191 8 and says stones were
imbedded in it. He recovered from this op-
eration and was in good condition for some
time. Six months later he began having pain-
ful urination and passed large amounts of
gravel and had colic pains in the urethra. He
passed nearly one hundred stones through
the urethra and had some removed from a
pocket in the urethra apparently from a
dilatation behind a stricture. He has lately
noticed severe pain from a few minutes to a
half hour after urination.

Pneiimoperitoneiini. — Patient could not
pass catheter because of swollen urethra.
One large bladder stone visualized and sev-
eral smaller ones.

Diagnosis. — Recurrent stones in the blad-
der. Proved at operation.

Case: Mrs. C. E. R., age thirty-seven
years.

History. — Three years previous the pa-
tient had a lump removed from the right
breast and one year later a second operation
was performed. She has been having attacks
of pain in the right side for several years
which she thought were pleurisy. The past
two weeks she has been getting short of
breath but has very little pain.

Physical Examination. — Left pleura
markedly thickened. Friction rub on the
right side at the junction of the sternum.
Breath sounds diminished over the entire
left chest.

Roentgen Examination. — Fibrosis with
calcified glands extending well out in the
right lung. Free excursion of the diaphragm,
on the right side. The left lung is radiopaque
below the level of the third rib anteriorly.
Several round shadows one half inch in
diameter are seen in both upper lobes.

Pneumoperitoneum. — Effusion of the left
chest. Fluid in the peritoneal cavity which is
easily demonstrated. No adhesions, no car-
cinoma masses demonstrable.

Diagnosis. — Peritoneal tuberculosis.

THE USE OF CO, IN PNEUMOPERITONEUM*

By WALTER C. ALVAREZ, M.D.

From the George Williams Hooper Foundation for Medical Research, University of California

Medical School

SAN FRANCISCO, CALIFORNIA

A YEAR ago, when I began experimenting
■*• *- with pneumoperitoneum, it seemed to
me that it would never come into general use
unless some way were found of relieving the
patient's discomfort immediately after the
exposures were made. I felt that the tech-
nique would have to be modified in some
way so that we could do the work in the
office and not in the hospital. Some studies
on the absorption of gas from the intestinal
cavity had made me acquainted with the fact
that CO2 is absorbed much more rapidly than
oxygen. In July, 191 9, Dr. Taylor and I in-
jected the preitoneal cavities of a number of
rabbits with COo and found that it was ab-
sorbed in a few minutes. After convincing
ourselves that this gas was as harmless as
oxygen we started using it on patients in the
office. We found that whereas oxygen often
remains in the abdomen in sufficient amounts
to cause distress for four days after injec-
tion, the CO2 in no instance remained over
half an hour. Ordinarily the patient was re-
lieved of tension in twenty-five minutes.

Dr. Stewart has stated in a recent article
that he has tried to make the procedure suit-
able for office practice by withdrawing the
gas through a trocar after the plates are
taken. My experience with these patients
makes me very doubtful whether manv of
them would be willing to submit to a second
puncture while they are in pain. Moreover,
I would rather not make another wound, al-
though my experience with patients who
have been operated upon after inflation is in
accordance with that of others who have
found no sign of damage. In only one case
did I see a light strand of omentum adhering
to the scar. Another objection to deflation is
that it is hard to get all the gas out, and un-

*Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn., Sept. 14-17, 1920.

less this is done completely the patient is
going to remain uneasy.

TECHNIQUE

The introduction of the gas is simplicity
itself. I use as a measuring bag the rubber
cuff that comes with a sphygmomanometer.
This holds about a liter. It is connected with
the CO2 tank and with the needle. The air in
the tubing should be washed out with CO2
because the nitrogen in it will remain in the
abdomen for 10 days or more. No attempt
need be made to sterilize the gas. The needle
is sterilized and then thrust through a small
spot which has been painted with iodine. I
think there is no need for using novocain un-
less a very large trocar is employed. I use a
needle with a caliber slightly larger than that
of a lumbar puncture needle. I always clear
it first by injecting a few drops of sterile salt
solution. The injection is made generally at
a point in the middle of the left rectus near
the navel. I find it hard to get the patients to
take enough of the gas. It is easy with old
women who have lost weight and who have
flaccid abdominal walls, but it is very hard
with muscular men. I make it a routine to
give a quarter of a grain of morphin a half
hour before the injection. This unfortu-
nately often produces nausea and vomiting
later, but it seems the lesser of two evils
because one never can tell which patients are
going to complain bitterly. Even with the
morphin, some do complain of pain, particu-
larly in the right shoulder. Others do not
complain of much pain but break out into a
cold sweat and seem to be greatly distressed
mentally. Others again have paid very little
attention to the procedure, and one man got
off the table and went out to lunch with me.

The Use of CO^ in Pneumoperitoneum

I think the best evidence that the operation
is not a terrible one is the fact that two of
my patients, who did not take quite enough
gas the first time, A'okmteered to have the
work repeated.

The only disadvantage that I can see to
the CO2 technique is that one must work rap-
idly if a number of plates are to be secured.
We almost always take first a 14 x 17 plate
with the patient lying prone. This is devel-
oped immediately so that any special points
of interest can be focused on in other plates.
It is very helpful when the patient has not
much gas in his abdomen to rotate him
slightly so that the right side is a little higher
for the gall-bladder plates and the left side
a little higher for the spleen plates. In this
way one makes the most of the gas that is
there.

I made a few attempts to use mixtures of
oxygen and CO2, hoping that I might slow
down the deflation somewhat, but I promptly
gave this up because all the disadvantages of
oxygen were retained without sufficient com-
pensatory advantages from the COo.

Just a word as to the usefulness of the
method. If it were not for the distress to
the patient one would like to have a set of
these beautiful and instructive plates on
every individual who comes with intra-ab-
dominal troubles. Unfortunately, however,
the procedure is so alarming and distressing
to many patients that I do not believe it can
ever be used as a routine. I have found it of
most help in the diagnosis of gall-bladder
disease, especially in the early stages. I be-
lieve that daily we are slipping up on the
diagnosis of early cholecystitis. We should
be helping these people before they develop
more definite symptoms, before they get
stones and before they suffer irreparable
damage. to the liver and pancreas. One of the
remarkable things about this technique is
that it opens up a clear space between the
liver and the kidney. Normally, the bowel
should drop down out of this space; and in
a number of cases in which it did not do
that, operation showed the expected adhe-
sions and the expected gall-bladder disease.

In this way I have been able to help a
number of women who otherwise would
have gone on suffering, because I would not
have had the courage to advise operation in
the absence of most of the classical signs of
cholecystitis. Although some of the thick-
ened gall-bladders without stones show up
very clearly on these plates, it is most dis-
appointing that others do not. I have here
to-day a plate which fails to show any gall-
bladder shadow although it does show a
stone which gave symptoms for twenty-five
years. To be sure, operation showed that the
wall of the gall-bladder in this case was still
thin. Moreover, in spite of repeated attacks
of inflammation there were no adhesions to
the colon. In other cases it was hard to be
sure of the disease in the gall-bladder, even
at operation. The wall was not definitely
thickened, the bile was sterile, there were
only a few adhesions to the duodenum and a
large gland on the cystic duct. Nevertheless
the pathologist reported small abscesses, full
of bacteria, and the patient got well after
the cholecystectomy. I think these observa-
tions must keep us humble, and must make
us admit that the roentgen ray diagnosis of
early cholecystitis will often be impossible
and always difficult and uncertain.

In spite of these disappointments I still
feel that the gas technicjue is going to be
very useful. When the history and other
findings point strongly to .cholecystitis, and
when a series of plates, taken in the usual
way, leave the question undecided, I practi-
cally always resort now to this technique and
often get a definite answer. For a while,
after discovering the value of CO2, I kept
using O2 for special cases ; but the differences
in the distress of the two groups of patients
was so pronounced that I finally gave up the
use of oxygen entirely. I think that others
who compare the after effects of the two
gases will come to the same conclusion, and
that the use of CO2 will win out, unless some
one can find another gas which is absorbed in
perhaps forty minutes. Even then, CO2
might remain the gas of choice because it is
cheap and a common article of commerce.

TRAUMATIC PNEUMOCRANIUM

By ALFRED S. DOYLE, ^LD.

Assistant Roentgenologist, Universit}- Hospital. Roentgenologist to St. Agnes Hospital and
St. Edmond's Home for Crippled Children

PHILADELPHIA, PENNSYLVANIA

^ I ''HE subject of traumatic pneumo-
-■■ cranium is interesting inasmuch as
only a few cases of this condition appear to
have found their way into medical literature
within the past decade. In The American
Journal of Roentgenology of December,
1913, Dr. W. H. Stewart of New York
published what appears to be the first rec-

cases reported by Dr. E. H. Skinner. Dr.
W. H. Luckett, and one, not reported, by
\\'alter Dodd.

In January, 1919, Dr. Hollis E. Potter of
Chicago published a case in The American
Journal of Roentgenology and up to the
present time that seems to be the only one
on record in which the patient appears to

Fig. I. Lateral View of the Left Side of Head,
showing air in cranial cavity displacing anterior
portion of left hemisphere. The lines of the de-
pressed fracture in the left frontal and temporal
region are also shown extending down to the base.
Note that the fracture does not show well through
the air cavity, because of the over exposure in
this area.

ognized case of abnormal intercranial air
following fracture of the skull. It is interest-
ing to note that while in the case reported
by Dr. Stewart the air was on the right side
and in the case which I am now reporting
the air was on the left side, the condition
was not suspected clinically in either case. In
August, 1 91 8, Dr. George W. Holmes of
Boston published his case of air in the cra-
nial cavity, and referred in his article to the

Fig. 2. Lateral View of Right Side. There is no
difference in size of the cavit}', as it extends to the
midline of the skull.

have made a recovery either with or without
surgical intervention. It is possible, however,
that many cases of this condition presenting
no clinical svmptoms which would cause the
patient to have an .r-ray examination have
passed unrecognized and made a complete
recovery. The indication for operation
would seem to depend entirely upon the
symptoms, as is shown by the recovery of
the case reported by Dr. Potter, in which
the patient made a complete recovery with-
out surgical interference, but at no time pre-
sented serious symptoms, and showed ab-
sorption taking place in subseciuent exam-

Traumatic Pneumocranium

inations. In our case the patient presented
symptoms which progressively grew worse
until serious damage had been done to the
frontal lobe of the brain and surgical inter-
vention was evidently too late to save the
patient. I have been unable to find any cases
other than those referred to above with the
exception of one reported by Dr. R. J. May
of Cleveland and in The American Jour-
nal OF Roentgenology of April, 1919, in
which case the plates were made several
hours after death. The condition is some-
what unique in so far as it is not recognized
or suspected until after the roentgen exam-
ination is made.

On June 7, 191 9, the patient was struck
by an automobile, at which time he received
lacerations of the scalp in the supra-orbital
region. He became unconscious and re-
mained so for several days, and then re-
gained consciousness, but complained of con-
stant and severe headache in the left frontal
region. He also complained of blindness in
the left eye. The left eyeball was slightly
sunken in the orbit. No operation was per-
formed at the time beyond sewing up the
wound., About the middle of August he be-
came very irrita1)le, but did not attempt vio-
lence either to himself or others. He also
began to suffer from attacks of vertigo, and
would faint three or four times a day.

About the latter part of August his mental
condition became worse, and he developed
auditory aphasia. When addressed he would
frequently give a totally irrelevant reply.
This condition became worse. His memory
did not seem to be affected, for he had no
difficulty in naming his nine children, stating
their ages, dates of birth and death, and he
seemed to be quite familiar with his circum-
stances and surroundings, and talked intel-
ligently on topics of every-day interest. For
some weeks previous to his admission to the
wards of the University Hospital he would
wet and soil his clothing, and claimed that
he had no knowledge of having done so. He
had evidently lost control over his bladder
and rectal reflexes. His appetite was not af-
fected and he slept well.

The patient was referred for roentgen
examination September 2, 1919, and during
the absence of Dr. Pancoast was examined
by me. Stereoscopic plates were made of
both sides of the head, also one postero-
anterior of the frontal region, and one
antero-posterior of the occipital region. The
examination was made presumably to
demonstrate a depressed fracture, which
was found in the left frontal and temporal
region. We were much surprised to find in
addition a large air cavity. The plates of the
left side (Fig. i) showed the fracture in-
volving the lower anterior section. The air
cavity was oval in shape with irregular
edges and measured 3^ by 2^ inches on
the left side plate and about 2^ inches in
width on the plate made of the frontal
region. (Fig. 3.)

Difficulty was encountered in obtaining
the consent of relatives for the necessary
operation ; valuable time was lost, the patient
gradually grew weaker, and the symptoms
became more pronounced. Consent was
finally obtained and operation performed
September 24th. The skull was trephined in
the left fronto-temporal region. The dura
seemed tense and under pressure and upon
opening it air rushed out with a hissing
sound. It was found that the frontal lobe in
this region was compressed by the confined
air and the brain tissue was soft and lacked
its normal resiliency. There was practically
no bleeding and no evidence of previous
hemorrhage. The dura was freed as far as
possible from the skull to permit it to col-
lapse and prevent the reforming of the air
cavity. The condition of the patient rapidly
grew worse and he died the next day.

The autopsy revealed two openings
through the dura and a depressed fracture
above the outer half of the orbit extending
over to the temporal region in one direction
and towards the cribriform plate of the
ethmoid in the other. The brain tissue in the
aft'ected area was soft and did not expand
after the air pressure had been released at
operation. Brain tissue was adherent over
the frontal sinus but no opening directly into

A Retinometer

the frontal sinus was found. The dura was This probably acted as a valve in admitting

adherent to the skull in many places, and the and confining the air.

air was under the dura. The fracture ex- The unusual features of this case were:

tended into the ethmoid sinuses, into which (i) The length of time the patient lived

Fig. 3. POSTERO-ANTERIUK ViEVV, PlATE ANTERIOR, FiG. 4. AnTERO-POSTERIOR ViEW, PlATE POSTERIOR,

showing the lateral dimensions o£ the air cavity. showing limitation to left hemisphere.

with gradually increasing air cavity into

a probe was passed, aiid found a free pass

age into the nasal cavity on the left side, which air constantly gained admission from

Considerable thick mucous was found in the the ethmoid cells and could not escape. (2)

passage through which the probe passed. The condition was not suspected.

A RETINOMETER*

By a. HOWARD PIRIE, M.D.

M0NTRE.\L, CANADA

' I "" HE instrument which I present to you
-■■ was made in order to allow me to test
the sensitiveness of my own retina to the
fluorescent screen. I use it for this purpose
from time to time, but its chief field of use-
fulness is in its power to take up the atten-
tion of visiting physicians and surgeons who
come to the fluoroscope with retinae ren-
dered most insensitive by the light in which
they are accustomed to work. These visitors
to the fluoroscope are invariably willing to
go on using the retinometer till they are

readv to see the fluorescent screen to advan-
tage. The more visitors who come at one
time the better, as then there is competition
between them as to who will first develop
sufficient sensitiveness of his retina to be the
first to use the instrument.

The retinometer consists of three lumin-
ous discs, the largest is a triangle, the me-
dium sized one is oval and the smallest one
is a circle with a diameter of about i mm.
These three discs are kept in the dark by a
covering flap which is kept in apposition

•Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn., Sept. 14-17, 1920.

A Retinometer

with the discs by means of a spring. A string
a yard long is attached to the flap. By puUing
this string the discs are exposed. The free
end of the string has a luminous tassel for
the convenience of finding it in the dark. To
use the instrument the observer picks up the
tassel and pulls on the string; holding the
tassel in his hand, keeping the string taut he

Fig. I. Retinometer Closed.

places the tassel against
his temple, his eyes are
then at a distance of
one yard from the in-
strument and the lumi-
nous discs are exposed
to his view. He is now
in a position to gauge
the sensitiveness of his
retinae. Most observers
are able to see the lumi-
nous tassel at once. One

who has come into the dark room from out
of doors will be unable to see the large lumi-
nous triangle. But by going close up to it he
will see it and he can then recede from it
gradually, keeping it in view as his retina
grows more sensitive. When he can just see
the large triangle alone at the distance of the
length of the string (one yard) he will be un-
able to see the next brightest spot — the oval,
but by now going close up to it he will be able
to see the oval and by the time he can see the
oval at the distance of the length of the
string, he is ready to begin to use the fluor-
escent screen. Until he can see the triangle
and the oval in the dark his eyes are not in a
fit state to look at the screen. It is folly to
point out tuberculosis to a visiting physician
when his eyes are not sensitive enough to see
these two discs in the dark. Visitors to the
dark room seldom stay long enough to be

able to see the third luminous disc, bvit the
radiologist should be able to see it plainly
himself.

When finished with the instrument the ob-
server lets go of the string and it automat-
ically closes, thus protecting the luminous
discs from the action of light. The discs
shine more brightly in the dark after being

Fig. 2. Retinometer Open.

exposed to bright light and for this reason
they are always kept in the dark and only
exposed to view by the action of pulling the
string. They remain of constant luminous
power if they are not exposed to the light.
The three discs chosen for this instrument

Fig. 3. Retinometer in Oper.vtion.

are the standard discs of a company manu-
facturing them. I |)icked them out of a large
selection of standard luminous discs, and
have been using them for more than six
months during which I have noticed no
change in the power of their luminosity.

I have to acknowledge the help of the
^'ictor Electric Corporation in getting the
instrument up in its present shape, which
difl^ers considerablv from mv first model.

INTRACRANIAL CALCIFICATION*

By JOHN T. MURPHY, M.D.

TOLEDO, OHIO

' I ''HIS paper is the result of an interest
-■• in the subject aroused by the follow-
ing case :

CASE REPORT

Mrs. M. J. L. Referred by Dr. Pamment.

Occupation: Bookkeeper. Age forty-
seven. Married.

Previous History. — Negative except for
diphtheria in childhood. Perineal repair in
191 2. Menstruation began at eighteen years.
Stopped at the age of forty-two. Always
regular and no pain. Patient married at
twenty-four years and had her first child at
twenty-seven years, which died fourteen
months later of infantile paralysis.

Convulsions began some time after an
operation for repair of a perineal tear, in
191 2. At first they occurred about twice a
year, then four times a year and during No-
vember, 1 91 9, she had four. With two ex-
ceptions they always came on during sleep.
Her husband states that he would be awak-
ened in the early morning by her moaning
and would find her shivering, teeth set and
some frothing at the mouth. She would be
unconscious of the attack until the next
morning, when she would find that she had
passed her urine in the bed, and had a sore
tongue and a severe headache. She would
feel so tired and muscle sore that she would
not go to work that day. She has had more
or less headache, but noticed that the head-
ache was very severe and continuous the
whole month of November, 191 9. Has had
no nausea or vomiting. Has worn glasses for
some time but has not noticed that her eye-
sight was getting worse previous to this last
attack.

Present Complaint.

1. Paralysis of right arm and leg.

2. Inability to speak.

3. Drooling from right side of the mouth.

*Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis. Minn., Sept. 14-17, 1920.

4. Convulsions.

5. Headache.

History of Present Complaint. — On Nov.
29, 1 91 9, patient got up at the usual
time, dressed herself and went to the kitchen
to prepare breakfast, but was not conscious
of it. Her husband saw that she was not
well and insisted that she go back to bed.
He tried to have her drink some coffee but
she couldn't hold the cup. He put her to bed
where she slept almost continuously for
twenty-four hours.

Physical Examination. — Nov. 30, 1919.
Patient is a robust woman, lying in bed,
conscious but unable to talk. Head and
Neck: Right side of face is smoothed out.
Tongue protrudes to the right. Mouth is
drawn to left. Drools out of right side of
mouth. Right eyelid closes partly only. Pa-
tient tries to talk but cannot. Chest: Lungs
— negative. Heart : Borders normal, rate, 70,
rhythm good. No murmurs. Abdomen : Neg-
ative. Right Arm: Can move it part way to
head. Left Arm: Normal. Rig^ht Legf: Can
move it slighth
Pressure: Systolic, i
Wassermann: Negative. Spinal Fluid: Neg-
ative. Urine: Negative.

Since this time there has been a gradual
return of normal functions. No convulsions
since onset. As soon as the patient was able
to be about she was brought in for examina-
tion with the .r-rays. A stereoscopic set of
plates showed the following:

A series of fine calcified lines, each form-
ing part of a circle, was seen to lie above and
behind the sella and about midway between
the left side of the skull and the median line,
the whole making a barrel shaped shadow
with the long diameter transverse, size about
1/ inch in width by about ^ inches long.
There is also a distinct increase in the mark-
ing's of the frontal bones on that side.

Right Leg:
: Normal. Blood
30; Diastolic, 85. Blood

Left Leg

Intracranial Calcification

On reviewing the literature an exhaustive
study of the subject was found in the Johns
Hopkins Hospital Bulletin for October,
1916, in which the entire subject of the use
of the ,^'-ray in brain tumor cases was taken
up. The previously reported cases are re-
viewed. They are seven in number, all from
the foreign literature. To these are added six
of their own, found in a series of 100 cases
clinically demonstrated brain tumors.

calcification extended from the base upward
into the brain substance, one case of aneur-
ysm of the internal carotid artery, and two
cases of calcification above and very close to
the sella.

In The American Journal of Roent-
genology, 1 91 6, III, is a report of a case by
A. W. George, as follows: A man twenty-
three years old. Stereoscopic plates of the
head made in the lateral position show an

Fig. I. Showing Calcareous Mass in Left Side of Skull.

In the cases reported in the foreign lit-
erature Fittig observed three calcified areas
in the walls of a cyst in an occipital lobe;
Grunmach a calcified tumor in the pineal
gland; Algygi a basal tumor with areas of
calcification; Klineberger a tumor of the oc-
cipito-parietal region ; Steida a calcified
cysticercus, and Strater a calcified brain ab-
scess only recognized after operation ; Licht-
heim a calcified gumma also not recognized
until after operation. Schiiller in his book
reports five cases all of which are calcified
areas in the brain substance itself. Huerig
and Dandy's cases are as follows: One case
of calcification of the brain substance, one
case of calcification in the sella, one case of

area of about 3 cm. in diameter, posterior to
the sella, with apparently calcified walls. The
patient had been injured in the head while
playing football and was unconscious. Epi-
leptic attacks began about eighteen months
ago. Operation showed a small tumor situ-
ated just below the pia mater and adherent
to the mid frontal lobe, diagnosed as an en-
capsulated glioma.

In an endeavor to find out the general
experience of roentgenologists, I wrote to
twenty-five of the members of the Society,
asking them to give me their experience with
the demonstration of calcified areas within
the skull. Many of the letters spoke of the
calcification of the pineal gland, which was

Intracranial Calcification

considered as a normal finding. Except in
four instances the replies were negative for
other findings. Dr. Charles F. Bowen re-
ported one positive case in approximately
200 cases examined. The history is as
follows :

There was a calcareous deposit about
I inch long and ^2 inch wide which was
found to be lying just above the external
auditory canal about i inch from the inner
table. It was lying in the brain tissue. This
was removed at operation and his epilepsy
cured. The man had had a fractured skull
about fifteen years before. Dr. Bowen was
of the opinion that a small piece of bone
was driven into the brain tissue acting as a
nucleus for the deposit of lime. The speci-
men however failed to show any nucleus of
this kind. This was the only case in the ex-
perience of these men in which they were
able to show calcification in the brain Itself.
One man had had considerable experience
with calcified areas in the falx cerebri, the
"psammoma" of the textbooks. Two other
men called attention to the finding of calci-
fied plac[ues in the meninges. Other than this
the findings had all been negative.

The actual diagnosis of the case I have
reported is in no way clear to me. Whether
it is a cyst of the brain or an aneurysm of
the anterior cerebral artery I am not sure. It
is however clear from the clinical view-point
that its presence has at times caused changes
in the internal capsule; the absence of gen-
eral signs of pressure is noticeable, and al-
though the eyegrounds were not examined
at the time of the paralysis, later examina-
tion shows them to be clear.

Roentgenograms made recently of the
case seem to show that the tumor is less
clearly defined ; this however may be due
only to difference of technique. The fact that
the patient has been on small doses of
the iodides continuously since, may have had
some effect. She now is apparently in good
health, with no headaches and only a small
facial paralysis remaining.

REFERENCES

I. LiCHTHEiM. Cited by Schueller.

2. FiTTiG. Fortschr. a. d. Geb. d. Rontgenstrahlen,

1902-2, vi, 238.

3. Grunmach. Verhandl. d. dentsch. Ront.-Gesellsch.

1907, iii, 95.

4. Algyogi. IVien. klin. Wchnschr., 1909, 831.

5. ScHULLER, H. Centralbl. f. d. Grenzgeb. d. Med.

u. Chir., 1909, xii, 849-884.

6. GoTTSCHALK. Verhandl. d. dentsch. Rontg.-Ges-

ellsch., 1907, iii, 92.

7. Oppenheim. Arch. f. Psychiat., 1901, xxxvi, 303.

8. Church. A7n. J. M. Sc, 1899, p. 117.

9. Mills and PfahlEr. Phila. M. J., 1902, x, 439.

10. Dandy. Am. J. Roentgenol., 1919, vi, 26.

11. George, A. W. Report of interesting head lesions.

Am. J. Roentgenol., 1916, iii, 16.

12. Schuller and Stocking. Roentgen diagnosis of

diseases of the head.

DISCUSSION

Dr. W. F. Manges. I know but little about
the subject of the author's paper. I have seen
quite a number of calcified masses in the skull.
I have not come to the point where I want to
take the time to study the literature on the
subject, and unfortunately the cases are so
seldom operated, that we really don't get to the
final diagnosis in the matter.

I have recently had a case in which there
was a calcareous mass that was fully an inch
and a half in length and practically an inch in
its greatest width, irregular in outline, and
ver\' much more densely calcareous than is
shown in Dr. Murphy's case. This particular
patient had no symptoms whatever, except
headache. He was a clothing salesman, who
had been working up to within two or three
days of the time when I first examined him, but
he did have at that time very violent head-
ache. He stayed around the Hospital for a
while, and became dissatisfied about something
and went elsewhere. Finally someone started
giving him iodides — his Wassermann had been
negative both by blood and spinal fluid — but
with iodides his headache disappeared, and he
was apparently very much improved. I haven't
had a recent radiograph of him, so I can not
say whether or not there has been any change
ill the tumor.

In another instance, an adult, man, age
forty-five to forty-eight years, had been per-
fectly healthy all his life, w'ithout any history

8c.

Intracranial Calcification

of injur}- until just shortly before ni}- exam-
ination— I have, I believe, shown this case be-
fore this Society or some section of it previ-
ously— and the radiographs of the head showed
a dense "stone," I called it, in his brain, within
about a half inch of the cortex on one side. He
came to me for examination because he had re-
cently developed epileptic convulsions, never
having had any during early life, and no fam-
ily history of anything of the sort. What the
origin of that densit}' was, I haven't the faint-
est idea, but I think the injury he received
shortly before he came to me was severe
enough, and the weight of this thing sufficient,
that the trauma that otherwise would not have
been disastrous at all, set up an irritation which
v^as the cause of his epilepsy. He refused
operation.

Then again I have had a number of cases in
which these calcareous nodules were multiple
and scattered throughout the brain, near the
cortex, and deep in the brain, and in only one
instance did I have any idea as to what the
cause might be, and that was the case of a child
who gave a very definite history of tuberculous
meningitis, and I thought perhaps there had
been foci of infection in the brain at one time
which had healed by calcareous deposit.

Dr. W. a. Evans. We have been able to
classify intracranial calcifications under three
general heads. The first is the calcification
which occurs in cyst walls. These cysts have
been observed both in infancv and adult life.

Infants showing calcified C}st formation usu-
ally present evidence of impaired mental de-
velopment or a spastic paraplegia. The calcifi-
cations occurring in adult skulls are usually
associated with cysts which are secondary to a
fracture of the skull or subdural hemorrhages.
Plates of the head in a case recently referred
for skull examination, with a history of
epilepsy, revealed a calcification which oc-
curred in the brain substance, the distribution
of lime suggesting deep brain cyst.

Under the second heading are the deposits
of so-called "brain sand." Of special interest
at this time is the deposit of lime in the pineal
body, it being claimed by some observers that
the calcification of the pineal is evidence of its
degeneration, with resulting loss of function;
accordingly cases presenting abnormal sexual
development should present atypical calcifica-
tions of the pineal gland. In our experience,
there has been no constant connection between
early deposits of lime in the pineal gland and
precocious sexual development of thirteen, in
which we were unable to show any brain sand
in the vicinit}' of the pineal.

The deposits of brain sand in the falx cere-
bri, the so-called psammoma, should not be
considered as the same type as a pineal calci-
fication. Some pathologists classify them as a
true bone tumor or osteoma.

Under the third heading, and this is probably
the least important, is the calcium deposit in
the walls of the blood vessels, especially the
circle of Willis.

NEW ROENTGENOGRAPHIC TECHNIQUE FOR THE
STUDY OF THE THYROID*

By GEORGE E. PFAHLER, M.D.

PHILADELPHIA, PENNSYLVANIA

"IV /T Y experience in the study of the thy-
^^■*' roid roentgenographically, heretofore,
has been generally unsatisfactory. I have
seen no description of technic|ue that really
demonstrates the outline of the thyroid ex-
cept in very large thyroids or in the large

Fin. I. P.24454-D. Mr. J. S. Carcinoma of the
Thyroid. Note the size of the thyroid, but particu-
larly the irregular compression of the esophagus.

substernal thyroids. These have been studied
in the postero-anterior position, especially
by Drs. Crotti and Bowen in their excellent
paper presented before this Society in 1913.^
Since so large a number of the hyperthy-
roid cases are sent for roentgenotherapy, be-
cause of the excellent therapeutic results
obtained in the treatment of toxic goiters,

1 Crotti, Andre. The roentgen ray in intrathoracic
goiter and thymus hyperplasia. /. Am. M. Assn.,
Jan. II, IQ13, p. 117.

*Read at the Twenty-first Annual Meeting of The American

we have an excellent opportunity for a care-
ful study of this group of patients. There-
fore, in February of this year I determined
to investigate these cases as thoroughly as
possible roentgenographically, and have
finally developed a technicpe that is almost
universally satisfactory, because one can, by
this method, demonstrate not only the ab-
normal thyroid and the enlarged thyroid,
l)ut the normal thyroid. I know of no other
techniciue which will demonstrate the size
and outline of the normal thyroid.

It is well known that the reduction in the
thyroid bv roentgenotherapy is one of the
latest results obtained in the treatment of
the exophthalmic goiters, or Grave's disease.
I have many patients that have been cured,
but unfortunately I do not have their ori-
ginal roentgenograms ; that is. the roentgen-
ograms made of their particular cases at the
beginning of treatment. I am c^uite sure,,
however, that as this study is further de-
veloped and continued, we can record cpite
accurately the progressive reduction in the
size of the goiter. Measurement of the cir-
cumference of the neck in determining the
reduction of the goiter is very crude, for one
may actually have a reduction in the size of
the tumor, and yet an increase in the size of
the neck, because it is quite well known that
as exophthalmic goiter cases improve,
they begin to take on weight. In fact, in-
crease in weight is one of the earliest signs
of improvement. As they increase in weight,
naturally the circumference of the neck in-
creases due to the deposit of fat. and there-
fore the goiter may be reduced while the
circumference of the neck shows very little
reduction or even shows an increase. It can-
not, therefore, be depended upon as a
method of recording the progressive reduc-
tion of a goiter.

Roentgen Ray Society, Minneapolis, Minn., Sept. 14-17, 1920,

New Roentgenographic Technique for Thyroid Study

In a number of cases patients are sent
with symptoms of hyperthyroidism and one
can feel Httle or no enlargement of the thy-
roid, but since I have been using this method
of recording, I have not found one in which
there was not an actual enlargement of the
thyroid. I cannot say, however, that one does
not have hyperthyroidism without an in-
crease in the size of the thyroid. Occasionally
a patient complains of difficulty in swallow-
ing due to pressure in the region of the
thyroid and yet, by palpation, the enlarge-

and difficulty in swallowing or breathing
without being palpable.

This method may be of value in differen-
tiating malignant goiter from the benign
goiter — probably only in occasional in-
stances, however. In one case there was con-
siderable irregularity in the outline of
pressure upon the esophagus.

TECHNIQUE

The examination is made with the patient
in the standing posture. The position best

Fig. 2. P.29437-D. Moderate-Sized Goiter Showing
Marked Compression of the Esophagus.

ment is so slight (or entirely absent), that
it is difficult to understand how a patient
can have such symptoms without palpable
enlargement. By this method, how^ever, com-
pression of the trachea or pressure of the
esophagus can be shown and these s}'mptoms
explained. It is well known that even the
very large goiters may cause no pressure ef-
fects on either the trachea or the esophagus.
On the other hand, a very small goiter or
small adenoma may press posteriorlv and
cause a very distinct symptom of pressure

Fig. 3. P.28929-D. Note the Compression of the
Esoph.agus by a very small Goiter in a Case in
which the Goiter was not Palpable. Note the en-
larged lymphatic gland under the angle of the jaw.

showing the outline of the tumor is obtained
fluoroscopically. The patient's sternum and
the anterior portion of the neck is pressed
strongly against the fluorescent screen. The
chin is turned toward the side on which the
enlargement is most marked and tilted up-
ward as far as possible. This draws the thy-
roid up into position where it can be shown
in the plate. One's aim must be to get a good
lateral view of the neck, but both shoulders
should be as nearly as possible in contact

New Roentgenographic Technique for Thyroid Study

with the plate. I think it is entirely possible
that this same technique can be carried out
with the patient lying down upon the table ;
but in my own laboratory I have found the
above position more practical. The tube plate
distance is 25 inches. The tube is centered
midway between the lower border of the jaw
and the upper border of the clavicle and cen-
tered directly over the thyroid. I use 8 by 10
duplitized films and double intensifying
screens. The exposure will vary from three-
fourths to one and a quarter seconds, de-

DISCUSSION

Dr. L. Jaches. I would like to ask Dr. Pfah-
ler to describe the position again. I did not
quite get it.

Dr. p. M. Hickey. I was about to ask the
same question. I did not quite get the angle. I
thought perhaps he would again demonstrate
the exact technique.

Dr. B. C. Darling. I would like to ask Dr.
Pfahler if there is any possibility of confusing

F'g^ ^

A--*' M

;-^

w''''

itk

^^B ^^"^

^■M

E-%

^p-*^

^i^

-4

; jp^^^

*■■«

!^-

1 .^^

[. h^^ :^MP-^

^^^^H

wmSFT

JHUt

Fig. 4. P.2S176-D. Normal Thyroid. Note the
Smooth Outline of the Esophagus, and the size
of the Thyroid.

pending upon the thickness of the patient's
neck, with 35 milliamperes, and a 5 inch
spark-gap.

With the above technique it is possible
and advisable to examine every goiter patient
that comes to the office, making a definite
record at the beginning of treatment, and
making further records during the treatment
or at the end of treatment. Further use of
this method of examination and detailed
study will probably demonstrate more clearly
its usefulness.

Fig. 5. P.2S069-D. Showing Normal Thyroid in a
Patient that had p.een Cured of Exophthalmic
Goiter.

the sternocleidomastoid muscle in that position
with the shadow of the thyroid.

Dr. G. E. Pfahler (closing). Answering
Dr. Darling's question, if you study those
plates carefully, you can see the sternocleido-
mastoid and why it would not be confused
with the shadow of the thyroid. It was shown
in a number of the normal cases. If vou recog-
nize the normal, it is easy to recognize the ab-
normal by comparison. I merely present this
as a method and not as a final study. (Position
again demonstrated by Dr. Pfahler, with Dr.
Bowman as subject.)

THE AMERICAN JOURNAL OF ROENTGENOLOGY

Published by Paul B. Hoeber, New York City

Issued Monthly. Subscription, $6.00 per year. Advertising rates submitted on application.
Editorial office, 480 Park Av., New York. Office of publication, 6j-6g East 59th St., New York.

Official Organ of

THE AMERICAN ROENTGEN RAY SOCIETY

President

Arthur C. Christie, M.D.,

1621 Connecticut Ave., Washington, D. C.

First Vice-President

A. H. PiRiE, M.D.

Ro3'al Victoria Hospital, Montreal, Canada

Second Vice-President

C. A. Waters, M.D., iioo N. Charles St., Baltimore

Secretary

H. E. Potter, M.D., 122 S. Michigan Ave-, Chicago

Treasurer

W. A. Evans, M.D., 32 Adams Ave. W., Detroit

Executive Committee

Henry K. Pancoast, M.D., Philadelphia, Pa.

Alexander B. Moore, M.D., Rochester, Minn.

W. B. Bowman, M.D., Los Angeles, Cal.

Publication Committee

Isaac Gerber, M.D.,
Leopold Jaches, M-D.,
P. M. HicKEY, M.D.,

Librarian and Historian

H. W. Dachtler, 224 Michigan St., Toledo, Ohio.

Editor

H. M. Imboden, M.D. 4S0 Park Ave., New York

Associate Editor

Percy Brown, M-D., Boston, Mass.

Annual AIeetixg Central Section

The Second Annual Meeting of the Central
Section of The American Roentgen Ray
Society will be held on February 21, 1921, at
St, Louis, Missouri.

Communications regarding the program
should be addressed to the president, Dr. James
G. \^an Zwaluwenburg, Ann Arbor, IMichigan.
The chairman of the local committee. Dr.
Edwin C. Ernst, 412 Humbolt Building,
St. Louis, may be addressed concerning mat-
ters of arrangements.

Providence, R. I.

New York City

Detroit, Mich.

Anxl'al Meeting Western Section

The officers of the Western Section of The
American Roentgen Ray Society are mak-
ing plans for their second annual meeting.
They have selected Portland, Oregon, as the
place of meeting, and the time has been set for
May 27th and 28th. This time will permit of a
continuous trip for the western men who de-
sire also to attend the A. ]\I. A. meeting in
Boston.

The Pacific Coast Roentgen Ray Society
will meet at the same time and place, the two
oi"ganizations being the guests of the Portland
Roentgen Club, a very active organization of
specialists.

The Secretar}- of the Western Section would
welcome a visitor or two from the East with
papers or demonstrations, and can assure them
of a very enjoyable meeting. Address Dr. A\^ar-
ner Watkins, Box 1328, Phoenix, Arizona.

LAWRENCE HERSCHEL HARRIS

Lawrence Herschel Harris died at his
home in Sydney on September 13, 1920,

Lawrence Herschell Harris

Editorials

after a distressing illness of fifteen weeks due
to an encephalitis following influenza. He
was the last of Australia's pioneer roentgen-
ologists, having taken up this specialty in the
late nineties. He was appointed roentgenolo-
gist to Sydney Hospital in 1900, and at the
time of his death he was consultant to this
hospital and also director of departments of
Roentgenology at the Royal Prince Alfred
and Royal Alexandra Hospital for Children
in Sydney. He was made an Honorary Mem-
ber of the American Roentgen Ray So-
ciety in 1916 and was President of the Sec-
tion of Roentgenology at the Australasian
Medical Congress in 191 3. He was visiting
England in August, 1914, and volunteering
immediately left London on August i6th
with the Australian Voluntary Hospital for
France. Later he was transferred to No. 3
A. G. H. at Lemnos, and after the evacua-
tion of Gallipoli he was invalided to England
on account of his dermatitis growing worse.

For many years he had suffered patiently
with his hands. This did not affect his un-
commonly genial and courteous manner
which endeared him to the profession and
patients alike.

He was the first man in Australia to do
gastro-intestinal work, and as in everything
else the standard he set was of the highest.
He was always found to be most willing to
give others the benefit of his experience.
All roentgenologists in Australia owe a very
great deal to one whose charming personality
and high professional attainment will live
long with all. while to the large circle of
those more privileged to have known him as
a friend, the memory of that kind, generous
and true white man will be theirs always.
L. J. Clexdinnen.

TWENTY ' FIFTH ANNIVERSARY OF THE
DISCOVERY OF THE XRAY

The New York Roentgen Society cele-
brated the twenty-fifth anniversary of the
discovery of the ,r-ray on December 11. 1920.

The celebration was held at the New York
Athletic Club, New York City, and took the
form of a dinner with members of the Phila-

delphia and New England Roentgen So-
cieties as guests. Fifty-two members and
guests were present, with Dr. H. M.
Lnboden, President of the New York So-
ciety, acting as Toastmaster.

Following the dinner Dr. Percy Brown of
Boston proposed a silent toast to those
former members of the Societies who had
lost their lives as martyrs to the advance of
roentgenological science.

Prof. J. S. Shearer, speaking on "A'-Ray
and Research," drew attention to the large
part that branch has played in the discovery
of electrical science and especially of that
branch with which roentgenologists are con-
cerned.

Dr. F. H. Baetjer in discussing ".Y-Ray
Diagnosis, Its History and Present Status,"
recounted delightful reminiscences of the
early days of the work at Johns Hopkins
University in the late 90's and early part of
the present century.

Dr. C. W. Holmes followed with some re-
marks on the present status of A'-ray thera-
peutics, and the evening was closed by Dr.
W. D. Witherbee, who presented a "Prelim-
inary Report on the Effect of Y-Ray upon
Tonsillar Tissue."

Charles Eastmond.

REPORT OF COMMITTEE ON TEACHING

In recommending a course in roentgen-
ology for undergraduate medical students
your committee finds that it is not an easy
task to determine just what is the proper
amount of instruction to meet the actual
needs of the medical or surgical practitioner
without loading him with a mass of inter-
esting but technical information that he
cannot use.

In determining an ideal course, the ques-
tion that first arises is whether it is advis-
able to crowd into a curriculum already more
than full, another separate course, when it
is so intimately bound up in nearlv everv
other subject of the curriculum that hardlv
can any branch be properly taught without
dealing with its roentgenologic aspects. Does
a student then acquire in the other courses

Editorials

a sufficient knowledge of the subject to be
able to read and intelligently digest the roent-
genologic reports and illustrations in an ar-
ticle or lecture that has a roentgenologic as-
pect? Your committee finds that there are
two extremes with perhaps as cogent reasons
for one view as for the other. One of these
holds that roentgenology is a specialty for
those trained therein and that the medical or
surgical specialist be given only the results
of his investigations. This same argument
would apply with ecjual force to the patholo-
gist and clinical diagnostician. Who would
have the temerity to advocate leaving these
two subjects to the mercy of the teachers of
other branches ?

The other extreme tends to attempt to
make roentgenologists of all medical gradu-
ates and thus bury completely the subject as
a true speciality. There seems to be a middle
ground that can safely be adopted, one that
will acquaint the student with the scope and
usefulness of the agent, enable him to know
when to call in the services of the roentgen-
ologist, how to prepare patients for the ex-
ination, to understand the reports that are
submitted^ and to know how and whv the
conclusions have been reached — all this with-
out any practical knowledge of handling the
apparatus or any of the technique employed.

Your committee therefore submits the fol-
lowing as a fair minimum of instruction to
accomplish the ends that appear to be
desired:

(a) That the subject be taught preferably
in the junior and senior years.

(b) That a minimum of forty-two hours
be given each student.

(c) That the junior course consist of at
least three lectures and demonstrations as a
general introduction, and at least twenty-nine
lectures and demonstrations dealing with the
diagnostic field and therapeutic applications
as well as the dangers and methods of pre-
venting injuries.

(d) That the senior course be a minimum
of eight hours per student consisting of
demonstrations of clinical cases to the
sections.

It is especially desirable that the senior
students follow their cases to the roentgen
ray laboratory, see the examinations made
and the findings interpreted and reported.

The committee further recommends that
the use of roentgenologic methods be em-
ployed to the fullest extent practicable in the
teaching of anatomy, physiology and the
other fundamental subjects, and that there
should be the closest possible cooperation be-
tween these departments and the roentgen-
ologist.

A. L. Gray, Chairman.

F. S. BlSSELL
P. M. HiCKEY

J. S. Shearer
W. F. Manges
Couunittce on Teaching.

REPORT OF SECOND ANNUAL MEETING
EASTERN SECTION

The second annual midwinter meeting of
the Eastern Section of The American
Roentgen Ray Society was held in Atlan-
tic City January 28th and 29th, in the new
Chalfonte-Haddon Hall auditorium, with
the president, Dr. David R. Bowen, of
Philadelphia, presiding.

In point of attendance this was the largest
midwinter meeting ever held, and from the
enthusiasm expressed by those in attend-
ance, must be rated as one of the most
successful.

The Friday evening session was devoted
to diversified subjects on .r-ray diagnosis.
The Saturday morning session was devoted
entirely to subjects involving .ar-ray physics.
The Saturday afternoon session was given
over to a symposium on jir-ray therapy and a
symposium on lung diseases. The Saturday
evening session, as is customary, was de-
voted to the lantern slide exhibit. This ex-
hibit has come to be recognized as the place
where most roentgenologists bring their dif-
ficult and unusual cases.

The discussion at the morning and after-
noon sessions on Saturday developed the
feeling that there was need for coordinated
physical and pathological research in the

Book Reviews

therapy field. Special emphasis was laid
upon the necessity for pathological research,
the feeling existing that physical research
was advancing beyond the pathological. By
resolution the President was authorized to
appoint a committee to make recommenda-
tions to the parent society at its annual meet-
ing as to how this coordinated research
could best be done.

The commercial exhibit was an innova-
tion at midwinter meetings. There was a
large number of exhibitors and a great deal
of interest centered in the new apparatus
exhibited.

At the election of officers, held on Satur-
dav evening, Dr. J. M. Steiner of New York
was elected president for the ensuing year
and Dr. C. A. Waters of Baltimore, was
elected secretary. J. M. Steiner, Sec.

A CORRECTION

In the January number of the present
volume, page 24, there is an article entitled,
"Dislocation of the Carpal Scaphoid." The
word "scaphoid" is used throughout the ar-
ticle and in the legend. "Scaphoid" is an
error, as the condition is evidently a dislo-
cation of the semilunar bone.

BOOK REVIEWS

A. Dauvillier, Rcchcrclics Spectro-
inctriqiie, sur Ics Rayons X. (Thesis
presented to the University of Paris.)

This thesis describes the author's experi-
ments on the variation in .t"-ray spectra when
various tubes and methods of excitation are
employed. It is indeed fortunate that this
admirable piece of research has appeared at
this time, when such extravagant claims are
made for certain types of apparatus. It is
clear that we can never have a rational
basis for .t'-ray therapy until we know the
true distribution of the radiation from the
tubes. Without definite knowledge of this
kind we are quite unable to decide between
various operating devices or to coordinate
our work.

Omitting, in a brief review, the technical
details of the experiments, the points con-
sidered and the conclusions are briefly as
follows :

1. What variations in spectral emission of
.ST- rays are to be expected with difi^erent tubes
when operated on various available wave
forms ?

2. To what degree is the output of short
wave lengths influenced by the type of tube
and mode of operation ?

3. Are the limiting wave lengths observed

for different voltages in accord with the pre-
dictions of theory?

4. What are the practical indications for
therapy ?

As regards No. 3 above, the author finds
agreement with the theory and determines
the displacement of the wave length of max-
imum ionizing power toward the short wave
length portion of the spectrum. He points
out that the claims of superpenetration and
unusual homogeneity claimed for the Lilien-
feld tube are entirely unwarranted from the
data at hand, disposing very effectively of
the claim that spectral distribution varies
with cathode ray concentration.

The practical indications are in entire
accord with the views often expressed by
those familiar wnth fundamental physics and
who are not misled by experimentation in-
tended to support some preconceived notion
or widely advocated method of measure-
ment. The author's statement is as follows:

"The results mentioned permit standard-
ization of A--rays, thanks to the Coolidge
tube. We propose to replace the present pro-
cedures in dosage, empirical and naturally
lacking in precision, by some simple direct
measurements of tension, intensity of tube
current, distance and the duration of expo-
sure. The fundamentals standardized will be:

Book Reviews

"i. The type of tube: Tubes of pure elec-
tron emission.

"2. The target material : Tungsten.

"3. The wave form of the electromotive
force: Sinusoidal or preferably constant.
The independent variables will be :

"4. The maximum tension (measured by
a voltmeter).

"5. The mean intensity of current.

"6. The nature and thickness of the filter
used.

"7. The distance from focus to skin.

"8. The duration of exposure.

These conditions completely characterize
the radiation and permit its exact reproduc-
tion independent of all spectroscopic meas-
urements."

The author promises further investigation
to determine for all workable conditions the
actual spectrum distribution.

With such information as to the delivery
of radiation from the tube and the recent
exact study of absorption coefficients by
Richtmyer and Grant we shall be able to
eliminate the vagaries and uncertainties that
now beset .I'-ray therapy.

The work of this author and those who
supported and encouraged it is not only ex-
tremely valuable, but is a splendid example
of the true spirit of research. It was carried
on as an extra load during the turmoil and
strain of the war when so few were even
thinking of these unsolved problems.

J. S. Shearer.

Subscribers to The American Journal of Roentgenology visiting 7s[ety Tor\ City, are in-
vited to make the office of The Journal (69 East '^gth Street, T^ew Tor}() their headquarters. Mail,
pac\ages or baggage may be addressed in our care. Hotel reservations will gladly be made for those
advising us in advance; in this case, \indly notify us in detail as to requirements and prices. List of
operations in T^ew Tor\ hospitals on file in our office daily.

TRANSLAriOnS & ABSTRACTS

Roberts, Percy Willard, New York City.
Syphilitic and Tuberculous Joints. (Am. J.
Syphilis, April, 1920, iv, No. 2, 302.)

During the past four years he has observed
over two hundred bone and joint cases which
were undoubtedly of luetic origin and which
possessed the symptoms usually ascribed to
tuberculosis. It is interesting to note that
fifty-one of these cases were diagnosed as tu-
berculosis by twenty-six experienced surgeons
and treated on that basis for periods varying
from a few months to fifteen years. In some of
them there was a positive Wassermann of from
one to four plus, and in all of them there was
subsidence of active symptoms a few weeks
after the exhibition of mercury and potassium
iodide. The Treponema pallidum may produce
tubercles identical in structure with those in
which the tubercle bacillus is found. In both
lues and tuberculosis an affected joint will pre-
sent s_\mptoms of irritation and there will be
muscular spasm. In both diseases there ma}' be
enlargement of the joint with efi^usion and the
formation of pus, sterile on ordinary culture
media. There may be sensitiveness, limp when
a weight-bearing joint is involved and altera-
tion of attitude if the disease is ^•ertebral.
A'-rays may show a bone lesion in either dis-
ease, but contrary to accepted theories there
are usually no definite characteristics upon
which to base a diagnosis. 'Tn a series of fiftv
of the cases the Wassermann reaction was so
frequently negative in the face of other evi-
dence of spyhilis and satisfactory therapeutic
results that it may be said that in the late mani-
festations of inherited lues it is onlv occasion-
ally of value. The duration of the disease bore
no relationship to the possibility of treatment.
Two knee cases, one of six and the other of
ten A'ears' duration, recovered practically nor-
mal function, with regeneration of the necro-
tic bone area. A spine case of fifteen years'
duration gained sixteen pounds in ten weeks.
Three out of seven profuselv discharging sin-
uses in this case closed completely and the se-
cretion from the others became thin, watery,
and of small volume. When the patient passed
from observation, he was able to take long
walks and was leading a normal life. A hip

case of twenty-five years' standing in which
almost constant pain had been a predominant
symptom, became entirely comfortable in about
ten days. His Wassermann was positive. All
of these cases had been under continuous treat-
ment for tuberculosis from the onset of their
SNinptoms."

ROHDENBURG, G. L., AND PrIME, FREDERICK.

The Effect of Combined Radiation and Heat
on Neoplasms. {Archives of Surgery, Janu-
ary, 1921, II, No. I, 128.)

Low degree of heat applied for varying pe-
riods of time have a lethal action on neoplastic
cells in vitro, and this lethal action with proper
dosage is effective in 100 per cent of cases.
Histologic examination of tumors w^hich have
been treated by diathermy reveals cellular
changes similar to those observed in tumors
exposed to radiation.

Wood and Prime have shown that any tumor
may be killed by a sufficient dosage of either
radium or roentgen ray; but that in maiy in-
stances the patient will not survive the dosage
necessary to bring about the death of all the
cells of an internal, highly malignant carcinoma
or sarcoma. Our experiments demonstrate
that b}- combining radiation with an agent not
so destructive to the organism the field of use-
fulness of radiotherapeutic measures may be
extended.

While the principles worked out in the ani-
mal experiments here recorded are already be-
ing applied in the treatment of cases of neo-
plasia in human beings, the technical develop-
ment of the method and the evaluation of the
final results will require long and careful ob-
servation of the patients before its applicability
can be demonstrated.

Chase, Sumxer B. The Roentgen Ray in the
Diagnosis of Sinus Disease. {J. Iowa State
Med. Soc., December 15, 1920, x. No. 12,
404.)

Two positions are common!}' used, the pos-
tero-anterior and the lateral, the latter of which
is sometimes stereoscoped. The Caldwell posi-
tion is commonlv used for the frontals. One of

Translations and Abstracts

the earliest signs of malignancy in the antrum
is an even clouding in the plate with a slight
break in the outline of the wall. The plate
should be carefull}' examined for signs of teeth
such as are found in dentigerous cysts, and if
present the alveolar process should be exam-
ined for the loss of one or more teeth. These
cysts cause bone absorption and not bone de-
struction. Osteomata present a characteristic
appearance of a solid growth, while odonto-
mata show well defined walls enclosing one or
more teeth. A giant cell sarcoma presents the
usual trabeculated appearance. A malignant
growth is differentiated in the plate from the
clouding of an empyema or a thickened mucosa
by the fact that the bone itself is attacked. The
vertical position for the sphenoid examination
he regards as important, as by it can be deter-
mined the presence or absence of a large pos-
terior ethmoidal cell or a perisphenoidal cell
which sometimes lies adjacent to the sphenoid
and may simulate disease in this sinus. For in-
stance, the lateral plate will show a cloudy ap-
pearance of the sphenoid while the vertical
plate will prove this to be a large opaque eth-
moid lying adjacent to the sphenoid with the
latter clear. It also helps to determine on which
side to operate for pituitary tumor by the nasal
route because these sinuses are not sym-
metrical.

A differential diagnosis between polvps and
mucocele can not be made definitely although
the polyp is more liable to have associated in-
flammation of the mucous lining of the antrum
which would produce a certain amount of
clouding of the remaining portion.

He quotes experiments which Caldwell made
showing that the shadow cast by various fluids,
such as water and pus, was practically the
same and that mucous membrane soaked in
water casts a much denser shadow than dried
mucous membrane.

The roentgen ray is a valuable aid in the
diagnosis of accessory nasal sinus conditions
Anatomical details of practical surgical and
therapeutic im.portance are shown.

The history, symptoms and clinical findings
should be taken into consideration in inter^
preting the plate.

With properly taken plates, and ruling out
previous operative interference, blurring of the
margin, or entire extent, of the larger sinuses
is interpreted as a pathological condition in the
sinuses.

The obliterations of the septa in the small
sinuses as the ethmoids, with correctly taken
plates and no previous operative interference,
indicates pathology present.

The roentgenogram of the sphenoidal sinus
as to the condition of the lining of the sinuses
is still unsatisfactory.

In certain conditions the diagnosis of the
pathology present may be made by the jir-ray
alone.

Pathology is very rarely found in sinuses
that appear absolutely normal in the roentgeno-
gram, although it is possible in early acute
cases to have pus present with practically no
shadow shown in the plate ; and all clinical
means of examination should be used.

Steindler, Arthur. Congenital Malforma-
tions and Deformities of the Hand. (/. Or-
thopedic Surg., November, 1920, ii. No. 12,
639- )

This very interesting paper is enhanced by
the following classifications :

A. Deformities by developmental suppres-
sion, agenesis :

1. Congenital Defect of the Forearm
Bones.

2. Lobster Claw Hand.

3. Ectro-dactyly (A-phalangism),

4. Hemimelia.

B. By Developmental Arrest.

1. Syndactyly.

2. Sym-phalangism.

C. By Developmental Aberrations.

1. Polydactyly (some cases).

2. Hyper-phalangism.

D. Dysplastic Conditions.

1. Chondro-dystrophy.

2. Brachy-dactyly (some cases).

3. Fusion of carpal bones.

E. Polyglandular Dystrophy.

1. Polydactyly (some cases).

2. Macro-dactyly.

3. Arachno-dactyly (partial gigantism).

F. Contractures (Neurogenetic or amniotic).

1. Contracted Club Hand.

2. Contracted Fingers.

3. Amniotic contractures (non symmet-
rical).

The author confines himself closely to the
discussions of his classifications in the twenty-
five case reports which are summarized in the
following :

Translations and Abstracts

1. Of the 25 cases reported, hereditary ten-
dencies were in evidence in 5 cases, deformi-
ties of the hand being found iji other members
of the family in 3 cases, other deformities or
anomalies in 2 instances. Identical deformities
in family twice, one case of syndactyly and one
case of congenital club hand.

2. Complicating deformities of the extrem-
ities were found in 15 cases, among which
complicating deformities of the hand 4,
namely : Symphalangism in one case of syndac-
tyly; Syndactyly in one case of congenital ul-
ner club hand; Syndact)ly in one case of con-
tracted club hand, and syndactyly in one case
of lobster claw hand.

3. Complicating deformities of the spine and
thorax were found in 3 cases.

Rhachitic deformities of spine and thorax
in one case of syndactyly.

Congenital scoliosis with wedge shaped ver-
tebrae in one case of contracted club hand.

Elevation of scapula, wedge formation of
vertebrae and fusion of ribs in one case of
congenital contractures of the fingers.

4. Complicating signs of degeneration and
general developmental aberrations were found
in 5 cases.

Acrocephaly in one case of syndactyly.

Malformation of genitals, high palate in 2
cases of contracted club hands.

Cleft palate in one case of aphalangism.

Three cases of this group showed deformi-
ties and contractures in all extremities.

5. Birth complications were found in 4 cases.
Instrumental delivery in 3 cases (i syn-
dactyly, 2 congenital club hands).

Twin birth and cord constriction in one
case (contracted club liands and general
contracture).

6. Primary developmental errors were as-
sumed to be the causative agent in the majority
of cases, in one case only amniotic constrictions
could be held responsible; pol}glandular (en-
docrine) dysfunction was suggested in 3 cases
by malformation of the bones of the head and
genital hypoplasia.

Ormerod, F. C. On the Treatment of Oriental
Sore bv X-Ravs. {Lancet, October 30, 1920,
p. 893-)

During 1918-19 the author treated a large
number of oriental sores by applying jr-rays

and observed satisfactory progress in most and
cure in a large percentage of cases.

The advantages of the .r-ray therapy may be
enumerated as follows : i. The rays act directly
on the causative organism. 2. They are able to
penetrate unbroken skin or masses of diseased
tissue, thereby being efficient in ulcerated and
non-ulcerated sores alike. 3. Cases can be
ti-eated as out-patients and can very often con-
tinue their occupation. 4. There is no risk of
constitutional disturbance, the danger of der-
matitis or necrosis being absent with the doses
utilized. 5. The treatment is short, painless and
easy to administer. 6. Doses in awkward posi-
tions, such as the inner canthus of the eye, lips
and alae nasi can be very readily dealt with.

7. The scars left after healing are supple
and of such color after about six months as to
be barely noticeable.

In conclusion, the author suggests that .r-ray
therap}- may be of value in the treatment of
the allied forms of leishmaniasis — espundia
and kala-azar — as .ar-rays have an undoubted
effect on the Leishman-Donovan body.

Haret and Truchot. Radiotherapy of Sci-
atica. New Technique. {La radiotherapie de
la sciatique. Essai de technique nouvelle.
Bulletins et Memoires de la Societe de Ra-
diologie medicale de France, October. 1920,
No. y2, p. 122.)

These authors briefly review the work of
previous radiotherapists and describe the fol-
lowing as the technique they have used with the
best results in eighteen cases. In six cases of
sciatic neuralgia (pain symptoms only, with-
out atrophy or change of sensibility and with
normal reflexes) they got six cures with two
and three series of five sittings each. In twelve
cases of sciatic neuritis (continuous pain, mus-
cular atrophy, trophic trouble, troubles of sen-
sibility, abolition or diminution of the tendo
achilles reflex) they got seven cures with three
and four series of five sittings each ; three
cases much improved, with the same amount of
treatment, and two cases only slightly im-
proved, frankly considered as failures.

The authors refer to the differences of opin-
ion of the massive dose and divided dose en-
thusiasts. They recommend the use of the Cool-
idge tube, four milliamperes of current, with
twenty-five centimeter (ten inch) spark-gap;

Translations and Abstracts

anticathode-skin distance twenty-two centi-
meters (9 inches). The treatment was admin-
istered over the foramina of the fourth and
fifth lumbar vertebrae and the first, second,
third and fourth sacral vertebrae of the af-
fected side. In one class of patients, they gave
doses of three H. units measured under three
milHmeters of aluminum filter at eight day
intervals. A second group of patients received
I H. unit measured under three millimeters of
aluminum every other day with an interval
of one week's rest after five or six sittings. To
a third group during five consecutive days the}-
administered a daily dose of i H. unit meas-
ured under four or five millimeters of alu-
minum filter; then five days of rest. A new
series of five sittings was then given with a
daily dose of i H. unit followed again by five
days of rest and so on. The authors have
finally settled on this last technique as giving
them the greatest degree of success. The dif-
ferent cases varied in their response to treat-
ment, but generally one sees a definite improve-
ment by the end of the second or third sitting.
In a few fortunate cases, they have obtained
cure with two series of five sittings each ; they
have never exceeded four series on anybody.

James T. Case.

Duncan, Rex. Epithelioma of the Lip, with
Observations and Results in the Treatment
of Eighty Consecutive Cases with Radium.
(Urol, and Cutan. Rev., xxiv, No. 10, 586,
October, 1920.)

From a study of eighty consecutive cases,
the author reaches the following conclusions :
Epithelioma of the lip may occur at any age,
near or after the third decade and in the ab-
sence of any definite etiological factor. Any
wart-like, ulcerated or indurated lesion of the
lip which persists more than two months under
ordinary treatment, must be considered sus-
picious of malignancy. In questionable cases a
section for diagnosis followed by immediate
treatment is advisable. In the majority of
cases, the macroscopic appearance is typical
and a diagnosis can be made by a competent
observer. Epithelioma of the lip is always a
serious condition and should receive prompt
treatment.

Radium therapy yields a higher percentage
of cures than any other method of treatment.

There results less inconvenience, loss of func-
tion and disfigurement than from surgery or
other treatment. Palpable lymphatic glands
should be immediately treated with radium. If
unimproved after four weeks, they should be
resected and radium buried within the wound.
A uniform application over the lesion, and in
certain cases the burying of the proper dosage
within the tumor, are essential. This is obtain-
able only by the use of radium emanation.

Taft, a. Robert. The Comparative Value of
Radium and A'-Rays in the Treatment of
Keloid, Nevi, Angioma, Leukoplakia and
Other Lesions of the Skin and Mucous
Membrane. ( Urol. & Cutan. Rev., Vol. xxiv,
No. 10, p. 590, October, 1920.)

The. author's results with keloid have con-
vinced him that while the .ar-ray is a splendid
remedy and the only one until the introduction
of radium, yet the radium is even better.

In leukoplakia the hardest rays possible are
advocated by everyone, and this in conjunction
with the ease of application makes radium the
ideal remedy.

In acne vulgaris the large area to be covered
makes ;ir-ray the choice, but in acne rosacea
the author believes that radium is more
efficient.

In lupus vulgaris, lupus erythematosus, ring
worm, sycosis, etc., he has used the .r-rays with
such satisfactory results that he has hesitated
to make a change.

It has been noted that in some skin diseases
covering large areas, psoriasis for example,
limited treatment with ji'-ray and clearing up a
few lesions will result in a marked improve-
ment of all other lesions. This is said to be
due to some general effect. The author has
treated in this manner lichen planus, various
types of eczema, etc., and has seen many of
these clear up generally as a result of a few
local treatments. He believes the results to be
due to absorption of killed diseased cells with
formation of vaccines. It is so much easier to
produce a local reaction in definite small areas
that radium is better for this purpose than
.^•-rays. Three cases of chronic genital sores
were treated successfully within the last year
by radium.

Angiomata, especially of the lips, responds
well to radium, which is certainly the remedy

Translations and Abstracts

of choice although in larger growths fulgura-
tion followed by radiation is quicker and
easier.

Nevi are better treated by radium than by
any other method. Although warts respond
well to radium, a less tedious and less expen-
sive treatment is to be advocated in all but
selected cases.

WiLKiNS, W. A. The Diagnostic Value of the
X-Ray Examination in Pulmonary Tubercu-
losis (Canadian Med. Assn J., Vol. x, No.
II, p. 99, November, 1920.)

Since the earliest days of roentgenology the
aid of the .ar-ray examination has been invoked
for diagnostic assistance in cases of suspected
pulmonary tuberculosis and to-day its emplo}-
ment is a very important part of the routine
examination of the chest. Nevertheless, there
is considerable confusion concerning the inter-
pretation of the shadows seen on the plate.
The .r-ray appearances of pulmonary tubercu-
losis vary with the stage of the disease. The
shadow cast by the pathological tissues may be
of any degree of density, including the faint
filmy shadow of the very early case, the mot-
tling of the more advanced disease and the
dense shadow of the healed lesion. At times,
the first indications of disease will be detected
by the physical examination; at other times
the .r-ray alone will show the early changes
and the ;i;-ray affords the most accurate infor-
mation that can be obtained apart from the
autopsy, at least for the extent of the disease.
Usually when physical signs are present, the
.ar-ray will demonstrate the area of involve-
ment to be more extensive than was indicated
by the physical examination. No method or
combination of methods at present employed
will detect invariably the earliest signs of dis-
ease in every case nor decide positively at all
times the activity of a lesion. The ;r-ray will
demonstrate the site and the extent of the tis-
sue changes, and although usually it is pos-
sible to infer from the .ar-ray plate alone
whether the lesion is active or not, this de-
cision should be left to the clinician to make.
To discover on the ;tr-ray plate indications of
pathological changes in the tissues, usually re-
quires the support of cHnical evidence of dis-
ease, before concluding that the changes can
be due onlv to tuberculosis. Otherwise the dis-

covery may consist of nothing more than the
recognition of a condition which has long since
ceased to be a matter of medical interest. The
clinical support need not be confined to the
presence of physical signs within the chest, but
may be manifested by the presence of general
symptoms of ill health. Definite indications of
pathological changes in the lungs so often are
seen on the :r-ray plate, not only in individuals
who apparently are in perfect health, but also
in those who give no history of having suffered
from a serious illness at any time, that one is
forced to the conclusion that tuberculosis of
the lungs is frequently a mild disease, often
running its course from onset to recovery
unrecognized.

Davis, J. S. The Radical Treatment of Z-Ray
Burns. {Ann. Surg., Vol. Ixxii, No. 2, p. 224,
August, 1920.)

X-Ray burns are usually caused by the use
of A'-rays in the treatment of skin lesions, such
as psoriasis, eczema, superficial epithelioma ;
by frequent exposures extending over a long
period of time in the treatment of inoperable
or incompletely removed carcinoma ; by the
reckless use of the apparatus in the hands of
unskilled operators and by long fluoroscopic
exposures.

The author has had under his care burns
situated in almost every region of the body.
Some of them have been of the first degree,
where the skin is reddened ; a few of the sec-
ond degree, where blisters formed ; the vast
majority have been of the third degree, where
the full thickness of the skin and often the
underlying tissues were involved.

Recent ;ir-ray burns of all degrees should be
treated as ordinary burns but unless there is a
fairly prompt response to such treatment it is
a mistake to continue it.

Palliative measures should be used in burns
of the first degree. Paraffin films are often
comforting ; painting with collodion, or the ap-
plication of sterolin (Formula: Balsam of
Peru, 4 c.c. ; castor oil and Venetian turpen-
tine, of each, 2 c.c. ; alcohol, 95 per cent, 100
c.c), or some bland ointment, are useful.

In burns of the second degree, it is often dif-
ficult to tell at first the depth of such a burn,
as one which seems to be merely blistered will
turn out to be much deeper in places after the
blisters have been removed. Wet dressings

Translations and Abstracts

have been found more comfortable in these
cases than paraffin or ointments.

In burns of the third degree which do not
heal promptly and permanently by the usual
methods more radical methods must be
adopted. The ulcer and surrounding area of
induration should be excised with a wide mar-
gin out to and down to healthy tissue. After
excision the defect should be grafted imme-
diately if the base of the wound is of normal
tissue, but if doubtful tissue is left, grafting
should be deferred until granulations form.
The type of graft used should depend upon
the situation. The author uses "small deep
grafts" in the majority of instances, but has
used with satisfaction Ollier-Thiersch, or
whole-thickness grafts in selected positions.

Pedunculated flaps from neighboring tissues,
or from a distant part, have been of great use
in situations where a pad of fat, in addition to
whole-thickness, was necessary.

The best method of relieving the pain, aside
from the excision of the affected area, is to
divide the nerves supplying the area.

X-Ray or radium used in the treatment of
.r-ray burns has not been followed by any
benefit. Patches of keratosis on the .r-ray oper-
ator's hand, following frequent exposures
without protection, may be successfully treated
by freezing with carbon dioxide ice. Should
the patches ulcerate, complete excision with
immediate or subsequent grafting is the
method of choice.

In instances in which tendons have been de-
stroyed it is advisable to fill the defect with a
pedunculated flap of skin and fat, and later to
restore the tendon by the method best suited to
the particular case.

Where large areas are involved we seldom
excise sufficient tissue and infection sometimes
occurs in the margins of these wounds. There
may be sloughing of the entire margin of the
wound, although the excision has been appar-
ently complete. For this reason it is wise to
defer grafting, or the transference of a flap.

In fulminating infections occurring in areas
of the skin which have been burned by .r-rays,
prompt excision with a generous margin is
indicated. Amputation of the part may be nec-
essary to control the rapid spread of the
infection.

The author's after-results of excision with
grafting, or flap-shifting, have been most grat-
ifying. Function has been restored in many in-

stances and patients who have been incapa-
citated for years have been returned to their
former activities.

Denis, W., and Martin, Charles L. A Study
of the Relative Toxic Effects Produced by
Regional Radiation. {Am. J. M. Assn., Vol.
clx. No. 4, p. 555, October, 1920.)

Constant extension of the field of roentgen
ray therapy has brought into increasing prom-
inence the condition of "treatment sickness,"
the constitutional reaction which frequently
follows the use of massive doses of the hard
roentgen rays. The underlying cause of this
reaction is unknown. It has been ascribed to
various and diverse factors. A factor which
has been considered but little is one involv-
ing the question of the relative severity of
symptoms following radiation of different
parts of the body. The authors have collected
the results of experiments with rabbits under-
taken to determine whether by the radiation of
certain portions of the body roentgen ray in-
toxication is more easily produced and in miore
severe form than by radiation of certain other
portions.

It was found that a definite dose of roentgen
rays administered to the body of a rabbit pro-
duces a severe systemic reaction and death
only when some portion of the intestinal tract
lies within the irradiated area. Furthermore, it
is possible to produce a definite acidosis (low-
ering of the alkaline reserve) in rabbits by
administering a heavy dose of roentgen rays
over the abdomen. Such animals give no evi-
dence of suflfering from a' "roentgen ray ne-
phritis."

The results suggest the hypothesis that aci-
dosis may be a factor in "treatment sickness"
following abdominal irradiation.

Gunning, R. E. Lee. Z-Ray Manifestations
of Diseases of the Chest. (Illinois M. J., Vol.
xxxviii. No. 3, p. 196, September, 1920.)

The early diagnosis of pulmonary tubercu-
losis presents one of the most difficult clinical
problems. The .sr-ray is merely an added form
of examination but more exact. This form of
examination should never be neglected any
more than the stethoscope. It must be remem-
bered, however, that a negative ;r-ray exam-
ination does not mean a normal lung. Positive
evidence alone is of absolute value.

Translations and Abstracts

In all forms of chronic or sub-acute pulmon-
ary tuberculosis with the clinical diagnosis evi-
dent, radiology is used simply to (i) confirm
diagnosis; (2) differentiate pseudo-tuberculo-
sis; (3) study development; (4) disclose com-
plications; (5) furnish therapeutic indications.

The radioscopic appearance in these cases
shows the widest variations as does the path-
ology. All manifestations from questionable
shadows to absolute opacity or involvement of
entire hemi-thorax or both pulmonary fields
are seen. The most unexpected forms and lo-
calizations may be established. The stetho-
scopic signs may indicate severe involvement
and the ;r-ray negate this and vice versa.

Abnormal shadows are seen most often to
affect the apices and hilus in general. The
shadows are scattered, varying in density and
separated from one another by clearer spaces.
Tuberculosis develops through foci. In con-
firmed tuberculosis, abnormal shadows are
found on both sides but usually predominating
on the side first affected. In advanced cases the
shadows reach the lower lobes and the apices
become spotted with clear zones due to
cavitation.

SoiLAND, A. Cancer of the Lip. ( Urol. &
Cutan. Rev., xxiv, No. 10, 599, October,
1920.)

Every lip case should first of all be given
ji'-ray treatment to the entire neck and soft tis-
sues of the lip and jaws, and this should be
done most thoroughly. This procedure is now
followed in the writer's service, whether or
not glands are palpable. The lip lesion itself
is then attacked, the method used depending
upon the location and extent of the growth.
When the lesion is rather superficial and in-
volves not more than one-third of lip along
both marginal borders, radium alone is suffi-
cient. If it is a little more extensive and re-
flected downward over the skin surface, com-
bined radium and .r-ray give excellent results.
If the lesion is more extensive and of cauli-
flower appearance, electrical desiccation by
means of the Oudin bipolar method has given
splendid results. After the slough has passed,
careful radiation should follow.

Straight surgery of the lip is indicated only
where extensive resection is contemplated, and
should in all cases be supplemented by radia-
tion.

Weinberg, Joseph A. The Influence of the
Exposure of the Roentgen Ray on the Pro-
gress of Tuberculosis. {Arch. Int. Med.,
Vol. 25, p. 565, May, 1920.)

It is generally agreed that the best method
for diagnosing tuberculosis of the genito-urin-
ary tract is by the inoculation of the urine of
suspected cases into the peritoneal cavity of a
guinea-pig. However, this test loses much of
its practical value because of the time which
must elapse before lesions are apparent in the
animal after inoculation. This work was un-
dertaken with two purposes in view: First, to
shorten the time of development of tubercu-
losis; Second, to determine the role of lym-
phocytes as a factor in the protection of
guinea-pigs against tuberculous infection.

The author was unable to hasten the prog-
ress of the tuberculosis appreciably by expos-
ure of the guinea-pig to massive doses of the
roentgen ray.

The leukocytes of the blood stream are
markedly reduced in number by exposure to
the roentgen ray. The reduction is proportion-
ate to the length of exposure with a given cur-
rent and voltage. The lymphocytes are most
markedly affected.

The cells of the tubercle are probably de-
rived both from the local tissue and the blood.
The presence of the usual number of epithe-
lioid and large mononuclear cells in the tuber-
culous lesions of roentgenized guinea-pigs,
where there is a marked diminution of lym-
phocytes, indicates that these cells are not of
lymphocytic origin. The presence of an excess
of lymphocytes in and around the blood ves-
sels near the tubercles in non-roentgenized
animals indicates that cells are carried to the
lesions by the blood stream.

Sittenfield, M. J. New Roentgenotherapy in
Cancer (/. Am. M. Assn., January 8, 1921.)

The writer reports methods of jir-ray therapy
used in three German clinics visited by him last
summer. He states that they are using voltages
of 200,000 to 220,000, tubes having been de-
veloped to permit this. With this high voltage,
short waves are produced in sufficient quantity
to permit using heavy filters and still have
enough of an almost monochromatic radiation
left to be of practical value, and its physical
characteristics have been determined suffici-

Translations and Abstracts

ently well to know the amount of radiation in
tissues at various depths. He stated that in
passing through lo cm. of soft tissue, only 70
per cent of the total radiation reaching the skin
has been absorbed, thus permitting 30 per cent
plus scattering to be effective in tissue of that
depth. So he estimates that 40 per cent of an
erythema dose can be administered to a uterus
of the average patient without injury to the
skin, and that by using four ports of entry,
namely, front, back and two lateral, approxi-
mately a full destructive dose can be so given.

Summarizing, he says that the lethal dose for
carcinomatous tissue is 90 per cent of the skin
erythema dose, that for sarcoma 70 per cent,
for ovary 25 per cent. Fibromyomata respond
to one treatment, resulting in complete castra-
tion.

Carcinomata of the breast is not so situated
as to permit of receiving approximately equal
amounts of ray in front and behind. Here,
though, the tumor is rarely more than 5 cm.
from the skin surface; so by increasing the
skin-target distance to 70 to 90 cm., 85 per cent

to 90 per cent of an erythema dose can be ad-
ministered to the tumor without injury to the
skin, as the effect is in inverse ratio to the
square of the focal distance. The time required
is 320 to 535 minutes.

The technique as reported for uterine can-
cer in Bumm's Clinic in Berlin is to ray four
areas, one in front, one from behind, and one
from each side, using a voltage of 190,000 to
200,000. The skin-target distance is 30 cm.,
and with a filter of 0.8 mm. of copper for
ninety minutes over each area. Blood transfu-
sion follows this treatment.

At Seitz and Wintz's Clinic in Erlangen, six
or seven fields are exposed, using 23 cm. dis-
tance, 16 inch parallel spark gap, 0.5 mm. of
copper or zinc filter for thirty-five minutes
each area. This treatment is given in two "sit-
tings" at six weeks' interval.

At the Opitz Clinic of Freiburg, the focal
distance is 50 cm. Four ports of entry are used
and each rayed for 120 minutes. Astonishingly
good results are obtained.

Eugene V. Powell.

THE AMERICAN JOURNAL
OF ROENTGENOLOGY

Editor, H. M. Imhoden, M.D., 7<iew Yor\

VOL. VIII (new series)

MARCH, 1 92 I

No. 3

THE DIAGNOSIS OF PRIMARY TUMORS OF THE LUNG^

By ARTHUR C. CHRISTIE, M.D.

Professor of Roentgenology, George Washington University Medical School,

WASHINGTON, D. C.

CONSIDERATION of primary tu-
mors of the lungs must deal largely
with malignant tumors, since those of henign
type are exceedingly rare.

The most comprehensive and accurate de-
scription of primary malignancies in the
lungs is the monograph of Adler, published
in 1912. Adler states that the first accurate
knowledge of lung tumors dates from mod-
ern times, after Laennec had established the
clinical investigation of the chest on a sound
basis by application of ausculation and per-
cussion. This he calls the period of the study
of lung tumors by clinical methods sup-
ported by gross pathology. His latest period,
coming down to the time of his monograph,
is that in which histology is added to clinical
and gross pathological research. Since the
publication of Adler's treatise the perfection
of the roentgen method of examination of
the chest has brought us to another period of
much greater accuracy in diagnosis of intra-
thoracic neoplasms. Indeed, Adler wrote as
follows in 1912: "It was not very long ago
that A. Frankel wrote that .r-rays were of
little service in the diagnosis of lung tumors.
Since then the .r-rays have become a most
remarkable and efficient aid to diagnosis in
general, and there exists the well-founded
hope of their increasing efficiency as fur-

ther improvements in apparatus and ad-
vances in techniciue are made The

hope may reasonably be entertained that
with the systematic and proper application
of the .r-rays to the exploration of the chest,
the diagnosis of lung tumor may be assured
when no other means will give ecptally cer-
tain results."

In 191 7 IMcMahon and Carman, in a
communication on "The Roentgenological
Diagnosis of Primary Carcinoma of the
Lung," described in detail the roentgen ap-
pearance of these tumors and gave the es-
sential points in differentiating them from
other intrathoracic conditions.

It is the purpose of this paper to state as
concisely as possible the diagnostic points by
which we are now able to \recognize the pres-
ence of primary tumors in the lungs and to
emphasize certain conditions that have come
under the writer's observation from w^iich
such tumors must be differentiated.

It is undoubtedly true, as several writers
have stated, that there is a certain roentgen
picture that is practically pathognomonic of
primary carcinoma of the lungs, but there
are certain other conditions .so closely re-
sembling it that constant watchfulness is
necessary to avoid mistakes. It is essential
in every case to interpret the roentgenogram

"Read at the Twenty-first Annual Meeting of The American Roentgen Rav Society, Minneapolis, Minn., Sept. 14-17, 1920.

Diagnosis of Primary Tumors of the Lung

in the light of the symptoms, the physical
findings, and especially the mode of onset
and course of the disease. ( Unfortunately,
like malignant disease in other parts of the
body, tumors of the lung may be almost or
cjuite symptomless, l3ut in any case of sus-
pected intrathoracic disease the possibility
of lung tumor should always be considered.
The symptoms and physical signs depend
not only upon the size of the tumor but
more particularly upon its location.

amination is made at this time, definite signs
of pathology will be seen, depending upon
the type of disease. If it is of the infiltrative
t}-pe, having its origin in one of the large
bronchi near the hilus, a roughly circular
shadow will be seen extending outward
from the hilus. The outer edge of this
shadow is not sharply circumscribed but
shades off into the surrounding lung shadow
and has projecting from it processes that
radiate out into the lung. Bevond this

Fig. I. Pri.makv Carcixoma of the Lung.

Fig.

Bexigx Tumor — Pkoharly Intrathoracic
Goiter.

There are usually no earlv svmptoms that
are characteristic, ])ut there may be symp-
toms to arouse suspicion and lead to thor-
ough investigation. Among the earliest of
these may be a slight discomfort — at times
amounting to pain — in an area correspond-
ing to the liila of the lungs. There is often,
also, a slight, gradually increasing dyspnea.
Accompanying the discomfort and dyspnea
there may be a dry, unproductiA'e cough.

If these symptoms lead to careful physi-
cal examination of the chest, a small area of
dullness may be discovered, especially a wid-
ening of the area of dullness about the root
of the lung. There may also be diminished
breath sounds, but no rales. If roentgen ex-

shadow which represents the pathological
process itself is a more or less extensive
area, somewhat less dense than the tumor
shadow, and quite homogeneous in charac-
ter. This is caused by congestion in the sur-
rounding lung and probably also by a partial
atelectasis due to some degree of stenosis of
the bronchi. If in addition to the above pic-
ture there are a few nodules with the same
indistinct edges surrounding the central
shadow or in relation with the bronchial
trunks farther toward the periphery, the pic-
ture is cjuite characteristic of malignant dis-
ease of the lung.

The infiltrative type of tumor may also
arise from subdivisions of the bronchi or

Diagnosis of Primary Tumors of the Lung

from bronchioles far out in the hmg struc-
ture. They show the same inchstinct edges
and projections as those arising at the hila.

In the miHary type of the disease there is
diffuse nodulation throughout the huigs, but
each nodule or mass of nodules has this
same hazy appearance at its periphery, and
there is present the surrounding zone due to
congestion.

If the appearance described above is pres-
ent, it may then be stated with a good de-

correct diagnosis by the presence of enlarged
lymph-nodes in the neck. The microscopic
examination of such a node removed from
the neck or axilla may show the character of
the process in the lung. The nature of the
disease has occasionally been determined by
the presence of portions of tumor in a
pleural effusion. A hemorrhagic effusion is
strongly suggestive of malignant disease.

It is stated that the diagnosis is some-
times established by bronchoscopic examina-

FiG. 3. Benign Timor, Probably Dermoid Cyst.

gree of certainty that the lesion is carci-
noma. There are, however, numerous cases
of lung carcinoma in which the roentgen ap-
pearance is not entirely typical, and there
are also conditions which are not carcinoma
in which the roentgen appearance closely
simulates the latter. It is in such cases that
we must rely upon the future course of the
disease and corroborative clinical findings in
order to establish a diagnosis. The sputum
may furnish conclusive or corroborative evi-
dence. In rare cases tumor elements may be
found or the fairly characteristic raspberry-
jelly or prune- juice sputum may be present.
The sputum is often bloody as in other lung
diseases. The gradual increase in dyspnea
due to growth of the tumor into the bronchi
or trachea is a valuable sign. Barker men-
tions two cases in which he was led to a

Fig. 4. EcHiNococcus Cyst of Lung.

tion. Fever is of variable occurrence and is
probably due to the presence of inflamma-
tory reaction about the tumor. It may vary
from 99° to 102.5°.

Two cases of lung carcinoma which have
come under the writer's observation depend
for diagnosis upon the manner of onset, the
progressive course of the disease, and the
roentgen findings, which are quite typical.
Both of these cases were men between fifty-
five and sixty years of age. The clinical and
roentgen aspects of these two cases are
strikingly alike. In both cases the first sign
of the disease was a sudden attack of fever
and cough. The fever disappeared in a few
days, but the dry cough persisted. In one of
the cases there were several attacks of fever
varying from 99° to 102.5°. One came for
roentgen examination eight months, and the

100

Diagnosis of Primary Tumors of the Lung

other six months after the initial attack of
fever. In one of them the cHnician had dis-
covered a definite area of duHness extending
outward from the left hilus — in the other no
suspicious physical signs had been found in
the chest. In both cases the most prominent
symptom was the persistent, irritating
cough, but both complained of a feeling of
tightness and discomfort in the region of the
root of the left lung. Both patients had a
slightly cachetic appearance and both had

cannot be stated. For example, Figures 2
and 3 undoubtedly represent benign tumors
since they were both observed over a period
of more than three years without change in
size or contour. Figure 2 is probably an
intrathoracic goiter, while Figure 3 is very
likely a dermoid cyst.

Echinococcus cyst sometimes occurs in the
lung, usually in the lower right lobe. Figure
4 represents a cyst which is believed to be
echinococcus, but conclusive evidence such

Fig. 5. MEDLA.STIXAL Tumor.

lost a few pounds in weight. Both cases
have been given two series of roentgen treat-
ment through many portals of entry with no
apparent improvement. One has been under
observation about four months, and the
other about six months, and in both there
has been a gradual increase in the cachetic
appearance and a gradual loss of weight.
Figure i shows the roentgen appearance in
one of these two cases.

Benign tumors of the lung occur infre-
quently but often enough to make it neces-
sary to mention them briefly. It is often pos-
sible to make a diagnosis of benign lung tu-
mor when the exact nature of the tumor

Fig. 6. Medlvstinal Tumor.

as booklets in the sputum or positive comple-
ment fixation test, was absent. The round or
oval, sharply circumscribed contour of be-
nign tumors and their smooth margin makes
their roentgen appearance rather typical.

The following intrathoracic conditions
mav simulate lung tumors more or less
closely and must be considered in the dif-
ferential diagnosis.

Mediastinal tumor can usually be dis-
tinguished by the roentgenologic appear-
ance. Oblique examination will show a dis-
tinct mass in the mediastinum, and exam-
ination in the antero-posterior direction will
.show the shadow directly continuous with

Diagnosis of Primary Tumors of the Lung

lOI

that of the mediastinal structures. (Figs. 5
and 6.)

In mediastinitis there is a general widen-
ing of the mediastinal shadow, and those

Fig. 7. Intrathoracic Goiter.

signs and symptoms that accompany an in-
flammatory process.

IntratJioracic goiter and cystic tumors of
the mediastinum give a rather characteristic
roentgen picture. (Fig. 7.)

Giinuna of the lung is a condition having
much the same roentgen appearance as ma-
lignant tumors (Figs. 8 and 9). The diag-
nosis depends upon the Wassermann test
and the disappearance of the mass under
anti-syphilitic treatment.

Caseous pneumonia may readily be mis-
taken for malignancy. The early symptoms
may be c[uite indefinite just as they are in
malignant disease, and the roentgen picture
may not be distinctive. The irregular tem-
perature, gradually becoming higher as the
disease progresses, the presence of rales, the
finding of tubercle bacilli in the sputum, and
the character of the sputum may serve to
dift'erentiate from lung tumors.

There are certain inflammatory processes
occurring at or near the hila of the lungs
that give much the same roentgen appear-
ance as malignant disease. Such conditions
are often seen following influenza, but they
may arise quite independently of other dis-
ease. We have observed several such cases
apparently caused by the streptococcus he-
molyticus. These conditions are sometimes a
Ijronchial adenopathy but some of them are
undoubtedly localized pneumonic processes.
Most of them undergo resolution very
slowly and it is at this time, when the patient
is afebrile, that a mistake may be made in

Fig. 8. Gumma of Lung.

Fig. 9. Gumma of Lung. Same Case as Fig. 8 after
Treatment.

I02

Diagnosis of Primary Tumors of the Lung

diagnosing the condition as mahgnancy of
the lung.

There are other conditions, such as bron-
chiectasis, chronic puhnonary abscess, en-
cysted empyema, puhnonary infarct, and
metastatic mahgnancy. that may be con-
fused with primary malignant tumor of the
lung. Careful attention to the history and
the roentgenologic findings will in most
cases serve to separate them.

It may be stated in conclusion that an
accurate diagnosis of lung tumor, with a
definite opinion as to its malignant or benign
character, can be made in many cases by
consideration of the mode of onset, the pre-
liminary symptoms, and the roentgen find-
ings. When, however, the roentgen appear-
ance is not characteristic, the diagnosis must
be established by the further course of the
disease, and the presence of such signs as
enlarged lymph nodes in the neck or axilla,
and the character of the sputum and pleural
effusions.

It must further be kept in mind that there
are certain non-cancerous conditions occur-
ring in the lung which may readily be con-
fused with cancer, especially if only the
roentgenologic evidence is relied upon.
Among those especially likely to lead to error
are gumma of the lung, mediastinitis,
caseous pneumonia, and certain inflamma-
tory processes about the hila.

REFERENCES

Adler, I. Priman- malignant growths of the knigs

and bronchi. Longman's, London, 1912.
Barjon, F. Radio-diagnosis of pleuro-pulmonary

affections (Translated by Honeij). Yale University

Press, New Haven, 1918.
Barker, L. F. The neoplastic pneumopathies.

Moiiogr. Med., 1916, ii, 548.
Black, H. R. and Black, S. O. Teratoma of lung.

Am. J. Surg., Jan., 1918, 67:73.
Blumgarten, a. S. Primary malignant tumor of the

lung. Med. Clin. N. Amer., Jan., 1919, ii, 1145.
Crow, L. B. Echinococcus disease of the lungs. Am.

J. Roentgenol., Nov. 1918, v, 513.
Edlavitch. Primary carcinoma of the lung. J. Am.

M. Assn., 1914, Ixxiii, 1364.
Engelbach and Schnoebelen. Malignancy of lung.

/. Roentgenol., June, 1919, ii, 193.
Galliard, L. Cancer of the lung. Bull. Soc. rned.

hop., Paris, March i, 1918; also /. Am. M. Assn.,

Ixx, No. 24, 1897.

Rall, R., Jr. Gumma of entire left lung. Lancet,

Dec. 7, 1918, ii, 779.
Martz, L. a. Lung neoplasm. J. Roentgenol., June,

1919, ii, 248.
McMahon, F. B., and Carman, R. D. The roent-
genological diagnosis of primary carcinoma of the

lung. Am. J. Med. Sc., 1918, xlv, 34-47.
Packard, M. Primary malignant neoplasms of lung

and pleura. A". York State J. M., Dec, 1918, xviii,

472.
Parkinson. Primary sarcoma of lung. Brif. J. Child.

Dis., Jan. -Mar., 1918, xv, 28.
Ric.\LDONi, A. Latent cancer of lung. Ati. Fac. de

Med., Montevideo. Nov. & Dec, 1918. Also /. Am.

M. Assn., Ixxii, No. 21, 1580.
Stevens, A. A. Malignant disease of the lung with

special reference to sarcoma. Ain. J. Med. Sc,

1912, cxliv, 193.
Taylor, H. E., and Caine, C. E. Sarcoma of lung.

Case report. Minn. Med. J., April, 1918, i, 191.

DISCUSSION

Dr. G. E. Pfahler. — This paper has been so
beautifull}- presented I don't see that there is
very much to add. I can only congratulate Dr.
Christie on his presentation.

Dr. F. W. Manges.— I too think Dr. Chris-
tie's a most interesting and important paper. It
has been but a comparatively short time that
we have been considering primary carcinoma
of the lung, except as a very rare entity, if an
entity at all, and I think largely because of the
roentgen signs which we found difficult to ex-
plain otherwise. In other w^ords, it has been
because we have not been able to diffei"entiate
our findings clearly that the diagnosis of pri-
mary carcinoma has become quite common in
the last few years, so that I think this is a most
important question now, especially to i^oentgen-
ologists. Every }ear our problems of differen-
tiating conditions in the chest are becoming
more and more difficult, more and more com-
plex. It must prove to all of us that we made
mlany mistakes in the past, so that I think the
paper of Dr. Christie, like that of Dr. Watkins
and a number of others on the chest at this
meeting, have been most valuable indeed.

I am not going to discuss the paper in the
sense tliat I disagree in any way with Dr.
Christie, because I don't. I would like to sup-
port practically everything he said.

Dr. George C. Johnston. — I have never
seen a case of pleural effusion in primary
nialignancv. It mav be that the cases are not

Clinical Importance of the Different Types of Pulmonary Tuberculosis

lO-

far enough advanced or that they die too soon,
or I don't get to see any of them. It is my
opinion you get your pleural effusion in sec-
ondary carcinoma.

Now, if we take up these cases of primary
carcinoma, pretty soon we will have the intern-
ist thinking about it when he is examining a
man, and you will find they are not at all rare,
but are simply overlooked. I have seen a num-
ber of cases of primary carcinoma of the lung,
and to my surprise, I found they were practi-
cally all coming from one man, and he was not
the best posted internist I had to work for,
either. He was one of the old school of men,
and in curiosity I asked him why he was mak-
ing so many diagnoses of carcinoma of the
lung that we could support roentgenologically.
He said it was probably because he was think-
ing about it when he examined the patient.
Then I asked him what he based his diagnosis
on in some of these cases, and he replied that if
you are going to explain afebrile hemoptysis
without any pneumonia, it is pretty hard to do.

Dr. a. C. Christie (closing). We often
have pleural effusions in primary carcinoma.

One of these cases of mine had a pleural effu-
sion, and many reported have had pleural
effusions which had to be withdrawn before
an accurate picture could be obtained.

I would like to emphasize what Dr. Manges
said that the disease is common. It is not such
an uncommon disease as we once believed and
we must think about it always. Adler reported
374 cases in 1912, and he accepted only those
which had been proven by pathologic section.
McMahon and Carman reported some 460
cases in 1918. There may have been quite a
number since, so there must be a great many
m.(jre cases than have been reported. Some
think it is not very important whether we make
an actual diagnosis or not, because the patient
is doomed any way, but I think it is a matter
of great importance to the patient. Aside from
the question of scientific accuracy in diagnosis,
it is of great moment to the patient whether he
is going to be moved around from here to there
as a tuberculosis patient for the rest of his life,
with the final destruction of false hopes that he
may get well, or whether it is definitely known
from the beginning that he has a malignant
disease.

THE CLINICAL IMPORTANCE OF THE DIFFERENT TYPES OF

PULMONARY TUBERCULOSIS AS DETERMINED

BY ROENTGEN EXAMINATION*

By R. G. ALLISON, M.D.

MINNEAPOLIS, MINNESOTA

T N attempting to classifv pulmonary tuber-
^ culosis into clinical and non-clinical types
by means of the .r-ray, I would like to assure
you at the outset that I am fully aware of
the difficulties that are to be met with, and
am convinced that it cannot be done without
a certain percentage of error. I am equally
convinced that unless we do attempt this
classification we have not done our full duty
either by the patient or by the clinician who
has referred him to us for an opinion. En-
tirely too much time has been spent by both
roentgenologists and clinicians in advancing
absurd claims as to the relative merits of
the stethoscope and the a--ray in discovering

*Read at the Twenty-first Annual Meeting of Thf American

the earliest tuberculous change in the lungs,
and entirely too little time spent by either of
them in investigating the clinical significance
of the lesions when found.

In the past there has been too much hesi-
tancy on the part of the roentgenologist to
make, and on the part of the clinician to ac-
cept negative diagnoses of pulmonary tuber-
culosis in the face of toxic symptoms.

Giffin of the Mayo Clinic says: "From the
comparison of the two methods we would
conclude that pulmonary tuberculosis can be
shown as early by the .r-ray as we can be
sure of its presence by other methods, and
the negative evidence obtained has in our

Roentgen Ray Society, Minneapolis, Minn., Sept. 14—17, 1920.

104

Clinical Importance of the Different Types of Pulmonary Tuberculosis

experience been of greater value than the
positive." Lawrason Brown of Saranac Lake
says; "By stereoscopic plates a diagnosis can
be made long before physical signs are defi-
nite." Rist of the Lannec Hospital of Paris
states: "To argue that a pulmonary tubercu-
losis sufficient to give physical signs would
not show definitely on the .t'-ray plate, shows
an ignorance- not only of the fundamental
principles of roentgenology, but of physical
diagnosis as well." Thus it would seem that
in stereoscopic plates we have the one accur-
ate method of definitely excluding pulmon-
ary tuberculosis.

It is my belief that the greatest factor in
making roentgenologists reluctant to make,
and clinicians reluctant to accept negative
diagnoses of pulmonary tuberculosis, has
been the non-recognition or non-acceptance
of the fact that there are no symptoms or set
of symptoms pathognomic of pulmonary
tuberculosis. Until clinicians and roentgen-
ologists accept this fact, the one will be al-
ways loathe to make and the other loathe to
accept a negative diagnosis in the face of
toxic symptoms. Further in this relation I
would include in the category of negative
diagnosis of pulmonary tuberculosis not only
normal lungs, but also lungs showing non-
clinical types of tuberculosis.

In my opinion our reports to the referring
physician should consist of an objective de-
scription of our findings, our impression of
these in terms of pathology, and finally our
opinion as to whether the lesion is or is not
a clinical type of infection. If all our cases
were referred by internists and tuberculosis
speciaHsts capable of translating objective
descriptions of shadows into terms of path-
ology either obsolete or recent, this might
not be necessary; but the majority of cases
do not come from them. It has been my ex-
perience that by far the greater number of
chest cases referred to the roentgenologists
come from the general practitioner ; and the
majority of these are sent for the simple
reason that they are presenting symptoms
suggestive of an active tuberculosis, with ab-
sent or ecjuivocal signs, and the information

which the physician desires can be summed
up in two cjuestions: (i) Has this patient
pulmonary tuberculosis? (2) If so, is it of a
type which could account for his symptoms?
It is my belief that the first cjuestion can be
answered correctly in practically every in-
stance. The second can be answ^ered with
such a high degree of accuracy, that it should
never be neglected, especially as it is the
question upon which the whole value of the
roentgen method depends. So much has been
written on the early diagnosis of pulmonary
tuberculosis, and the fact that physical signs
may be absent so emphasized, that as Rist
aptly expresses it, confronted by a patient,
our attitude is not "What ails the patient?"
but "Can't we find some tuberculosis to ac-
count for his symptoms?" It is in this type of
case — and these form at least half of the
cases we see — where by making a definite
negative diagnosis of a clinical type of tuber-
culosis, we can start the physician on a fur-
ther search for the real cause of the patient's
symptoms.

Otherwise, if we describe an obsolete tu-
berculosis as seen on the plates, without an
expression as to its clinical significance, the
physician will immediately attribute the
symptoms to it and the patient be doomed to
a sanitarium existence, with all the interfer-
ence with his future life which that entails.
Only a week ago I heard one of our noted
sanitarium physicians say: "It is only since ]
have become convinced of the value of a
negative .t--ray diagnosis of tuberculosis that
I found how many different conditions I had
been treating as pulmonary tuberculosis."

We as roentgenologists would be far more
accurate and valuable if we would confine
ourselves to speaking in terms of clinical and
non-clinical types of tuberculosis and base
our opinions wholly upon the findings of the
plates, rather than l)e biased by the patient's
symptoms, and attribute activity to an obso-
lete infection. Naturally the patient has
svmptoms or he would not have consulted
his physician, and his symptoms are sugges-
tive of pulmonary tuberculosis or he would
not have been sent to us. Our duty is to say

Clinical Importance of the Different Types of Pulmonary Tuberculosis 105

whether there is a pulmonary tuberculosis
present which is capable of producing symp-
toms, and there our duty ends.

I hope I may be pardoned for having dwelt
so long on these simple facts, but for
five years I worked in clinical tuberculosis,
and during part of that time I received dic-
tated chest reports. During that time the
reports were a conglomeration of "increased
linear markings," "bronchial interweavings,"
"tobacco smoke cloudings," and "apical
shadows," without any attempt generally to
convert these findings into terms of pathol-
ogy and anatomy and never any attempt to
state their clinical significance. Usually I was
more in doubt as to what the patient had af-
ter reading the reports than before. It is be-
cause I can see this from the standpoint of
the clinician that I have dwelt so long on the
necessity and value of an opinion from the
roentgenologists as to the etiology and clini-
cal significance of the objective findings.

From a roentgen standpoint all pulmonary
tuberculosis can be grouped under three di-
visions : ( I ) The pulmonary miliary pro-
cess which accompanies a generalized miliary
tuberculosis and is hematogenous in origin.
Its appearance is characteristic, readily rec-
ognized, and seldom confused with other
conditions. Its clinical significance need not
be touched upon. All pulmonary tuberculosis
other than this form can be classified defi-
nitely as either (2) parenchymatous or (3)
peribronchial, depending upon whether the
involvement is in the lymphoid tissue sur-
rounding the bronchus or in the air vesicles
themselves. In case both types are present it
should be classified as parenchymatous.

The roentgen differentiation of these two
types is simple, definite and necessary. It is
beyond the scope of this article to delve into
the different theories on the mode of infec-
tion in pulmonary tuberculosis.

Gohn's classical work on the lungs of chil-
dren would indicate that all peribronchial
tuberculosis is secondary to a parenchymal
focus, which may be active or healed, large
or small. Regardless of its etiology peribron-
chial tuberculosis can be definitelv differen-

tiated from the parenchymal form by the
^--ray. The roentgen appearance of paren-
chymatous tuberculosis from its slightest to
its most advanced changes is perfectly fa-
miliar to all of us and a description need n(jt
be indulged in. The only condition which
resembles it closely is an atypical bronchial
pneumonia, and here at times we must resort
to the time-honored custom of watchful
waiting in order to decide with which condi-
tion we are dealing. With a history of recent
influenza or pneumonia I should wait for a
few weeks, for a second set of plates, before
pronouncing a slight infiltration or consoli-
dation tuberculous unless there were definite
evidence of fibrosis or calcification present.

If the conglomerate tubercles which make
up this type of infection are few in number
and definitely calcified, and the linear mark-
ings extending toward the hilus from them
show a cleancut shadow, I do not consider
the lesion of clinical significance. Unless it
does exhibit this appearance I report it as a
clinical type of infection.

Peribronchial tuberculosis, to be consid-
ered of clinical importance, should be upper
or middle lobe distribution, gross in amount,
either unilateral or more marked on one side
as compared with the other, and should ex-
hibit a hazy outline and a definite nodular
appearance. Unless involvement of the peri-
bronchial tissue conforms to these qualifica-
tions it represents either a non-tuberculous
infection or is merely the residue of an ob-
solete tuberculosis.

I have followed the plan just outlined in
reporting all chest cases. I have first given
the objective findings, then attempted to con-
vert these into terms of pathology. Following
this I have then given a positive or negative
opinion as to the clinical significance of the
lesion.

I have probably missed several cases of ac-
tive tuberculosis, and I am quite sure that in
many of the cases I described as having a
clinical type of tuberculosis, the tuberculosis
was c|uiescent and the cases were suffering
from other conditions which w^re producing
their symptoms. But on the other hand I am

io6

Lateral and Oblique Studies of the Chest

quite sure that in most instances where a
negative diagnosis was given, the physician
by a further search was able to find some
other disease as the cause of the patient's
svmptoms.

COXCLUSIOXS

1. Pulmonary tuberculosis can be divided
into clinical and non-clinical types with a
high degree of accuracy by stereoscopic
plates.

2. Unless we make this division into the
two types we are putting our method on the
level of tuberculin, which will not differen-
tiate between infection with the tubercle
bacillus and the disease tuberculosis.

3. Negative stereoscopic plates can with

an occasional rare exception exclude a clini-
cal type of tuberculosis.

4. Parenchymatous tuberculosis is a clini-
cal t\pe unless slight in amount and definitely
calcified, and peribronchial tuberculosis is of
clinical significance only where it conforms
to the following qualifications, upper or mid-
dle lobe distribution, unilateral or more
marked on one side as compared with the
opposite, gross in amount and presenting a
hazy outline with definite modulations.

5. A negative diagnosis from the roent-
genologist is of more value than a positive,
in that in the face of suggestive symptoms, a
positive diagnosis can often be made by other
methods, but the .r-ray alone offers the only
accurate method of excluding the disease.

THE VALUE OF LATERAL AND OBLIQUE STUDIES

OF THE CHEST*

By WILLIAM A. EVANS, M.D.

DETROIT, MICHIGAN

T N reviewing the literature on tuberculosis
-■- in children, one wonders at the wide
variance of opinion held by men pro iiinent
in chest work as to diagnosis and location of
lesions. It is agreed that the diagnosis is
difficult, and while one writer insists that
phvsical signs are to be depended on first, if
not almost entirely, another declares that the
ordinarv methods of examination are of
little value, and that history alone will suf-
fice to determine the diagnosis.

References to the pulmonary area in-
volved are ecjually conflicting. Fishberg, in
an article in the Aledical Record in 1917,
states that parenchymal lesions are invari-
ably apical, as in adults. This is in direct
contradiction to the usual view that paren-
chymal tuberculosis in children is invariably
of the lower lobes. Most of the later
workers agree that the roentgen method of
examination of the chest is most valuable,
some declaring that it is the only method by
which a correct diagnosis can be made.

Inasmuch as parenchymal tuberculosis is
extremely rare in childhood, and peribron-
chial tuberculosis and a peribronchial lymph
node tuberculosis are but secondary develop-
ments of a primarv root infection, it is evi-
dent that the ordinary postero-anterior plates
of the chest cannot have a proper diagnostic
value for tuberculosis, since the visible
changes in this condition to a large extent
and for some time occur in the nodes which
surround the trachea and the first portion of
the bronchi, and these structures are ob-
scured by the heart and large vessel shadows.
We have had the opportunity recently to
check physical and radiographic findings,
and it has been observed in the cases in
which the infection had spread to the outer
bronchial, bronchopulmonary and pulmonary
nodes, the findings were in harmony, but
when the physical findings — and in these
cases the d'Espine sign was held diagnostic
— were not in accord with the pathology
demonstrated bv the ordinary plates, lateral

•Uead at the Twenty-first Annual Meeting of The .\merican Roentgen Ray Society, Minneapolis, Minn., Sept. 14-17, 1920.

Lateral and Oblitjue Studies of the Chest

107

Fig. I. Case i. An Ordinary Posterior-anterior Fig. 3. Case ii. Orijinary Postero-anterior Plate
Plate of a Child's Chest Showing the Ac- of the Chest of a Child. No Abnormality Noted,
centuation of the Hilum Shadows and In-
creased Markings Upwards.

Fig. 2. Case i. Lateral Plate ()f the Chest Show-
ing the Calcified Glands and Marked Hyper-
trophy of the Lymphoid Tissues in the Space
between the Heart and the Spine.

Fig. 4. Case ii. Lateral Plate of the Chest
Showing Extensive Deposit between the Heart
AND Spine.

io8

Lateral and Oblique Studies of the Chest

plates revealed the enlargement of the
tracheal and inner bronchial glands.

We are not to gather from these state-
ments that the diagnosis of tracheobronchial
tuberculosis can be made from the radio-
graphic examination alone, for there is noth-
ing characteristic about the enlargement of
the glands resulting from infection with the
Koch bacillus; but it is important to use a
method which will demonstrate the basis for
physical signs, and the lateral plate will do
this frequently when the standard positions
give negative findings.

At this time, I should like to refer to the
results of experiments by Krause given in a
paper entitled "Experimental Tracheobron-
chial Node Tuberculosis" published in the
American Reviciv of Tuberculosis, March,
1 91 9. In these experiments an attenuated
strain of Koch bacillus was injected in the
groins of guinea pigs. Serial studies demon-
strated an early and relatively extensive in-
volvement of all of the lymph nodes in the
vicinity of the point of infection. It was sup-
posed for some time that the infection did
not spread beyond the abdominal lymph
nodes, but later studies showed in all cases
involvement of the tracheo-bronchial nodes.
Dr. Krause' s conclusions from these experi-
ments tend to disprove definitely the Ghon
theory that all tuberculosis of the hilus
glands is secondary to a pulmonary paren-
chymal lesion. Dr. Krause suggests that he
could agree with Ghon's theory provided the
word infection was used rather than lesion,
because it is no doubt true that the Ivmph
nodes are, in many cases, infected by inhala-
tion, the organisms being absorbed by the
terminal pulmonarv Ivmph vessels.

The value of the lateral studv of the chest
in adults is particularly great in those cases
which present deep-seated abscesses or inter-
lobar -collections of fluid. The position of
parietal effusions can be easily determined
by plates made in both anteroposterior and
postero-anterior positions, the size of the
shadow, of course, varying on the two sets
of plates. The ordinary stereoscopic plates
are of no value in these diffuse intrathoracic
shadows, because the relation of the densitv

to the anterior or posterior chest walls can-
not be determined by this method of study.
If the margins of the encapsulated fluid were
always spherical or regular, the lateral
method would have no special advantage;
but frequently the outline of a retained fluid
is triangular, so that by the lateral plates the
points of approach for thoracentesis or
thoracotomy can be advantageously chosen.

The possibility of a successful drainage of
a lung abscess by collapse of the lung
through artificial pneumothorax can also be
determined in advance of the procedure, for
in abscesses which are situated near the peri-
phery of the lung, there are frequently ad-
hesions between the pulmonary and parietal
pleurae, which prevent lung collapse. This
question is especially timely because there
are many internists in the country who are
electing to treat acute pulmonary conditions
by artificial pneumothorax when the path-
ology present should demand surgical
treatment.

The shadow of the right leaf of the dia-
phragm on the average chest plate is at the
level of the eighth or ninth rib posteriorly,
the exact level depending on whether the
plates were obtained in deep inspiration or
in expiration. The lines of reflection of the
pleura inferiorly are anteriorly at the level
of the eighth costochondral junction, mam-
mar^• line, the tenth rib in the midaxillary
line, and thence to the spinous process of
the twelfth thoracic vertebra. The variation
between the two sides is unimportant.' There-
fore any pathology occurring in the posterior
phrenocostal space cannot be shown on the
standard anteroposterior plates. It is true
that plates made in deep inspiration reduce
the depth of this hidden field, but at no time
is the diaphragm entirely -flat. Again, any
inflammatory pathology involving the lower
lobes causes a fixation and elevation of the
diaphragm on the affected side, and the
depth of the area under discussion is cor-
respondingly increased.

The lower right lobe is a favorite locality
for abscess, probably due to the predilec-
tion for foreign bodies to enter the right
bronchus.

Lateral and Oblique Studies of the Chest

109

Fig. 5. Case hi. Ordix.\ry Postero-.\xterior Plate Fig. 7. Case iv. Postero-anterior Plate of the
OF .\N Adult's Chest Showing a Hydropneumo- Chest Showing a Hydrothorax.

THORAX.

Fig. 6. Case hi. Lateral Plate Showing the
Collection of Fluid in the Posterior Part of
the Chest. Note Fluid Level Overlying the
Shadow of the Spine.

Fig. 8. Case iv. L.a.teral Plate of the Chest
Showing the Wide Distribution of Fluid from
the Anterior to Posterior Chest W.^ll.

Lateral and Oblique Studies of the Chest

Descriptions of three cases recently
studied will serve to illustrate the practical
value of the lateral and obliciue studies of
this area.

Case I. Mrs. S, age forty-hve. Referred
for chest examination with the historv of an
acute process in the lower right. The find-
ings, at this time, were those of a small
amount of fluid in the right lower pleural
cavity, there being a loss of the phrenocostal
angle. However, the development and sever-
ity of the symptoms were out of proportion
to the findings, and following withdrawal
of the pleural efifusion. further studies were
undertaken to determine the basis for the
persistence of the symptoms. At this time,
by the oblique method, we could demonstrate
a rounded shadow just below the shadow of
the right leaf of the diaphragm, and acct)rd-
ingly a report was made that a lung abscess
was present, and that the pleural effusion
formerly demonstrated was simplv second-
ary to the deeper lesion. Several davs follow-
ing this examination, in a paroxvsm of
coughing, the patient brcnight up a peanut
with a quantity of pus. and the case went on
from this to complete recovery. At the time
of both examinations, no history whatever
was obtained that would suggest the pres-
ence of a foreign body.

Case II. Mr. C, age twenty-three. The
chest plates showed pulmonary pathologv in-
volving the lower right lobe, complicated
with a small amount of pleural effusion. The
patient apparently recovered from this con-
dition, although previous to his discharge
from the hospital no radiographic record
was obtained of the chest condition. After a
lapse of three months, the patient was again
referred for examination of the abdomen,
with a tentative diagnosis of duodenal per-
foration or duodenal ulcer. Stud\- of the
chest at this time re\-ealed a fixed and ele-
vated right leaf of the diaphragm, with no
free fluid in the pleural cavity. The abdom-
inal findings were those of adhesions involv-

ing the first and second portions of the duo-
denum. We described the pathology in the
lower lobe, but we did not appreciate its
clinical significance, as later events proved.

At operation, adhesions were found in the
upper right quadrant, but during the anes-
thesia, the patient had a severe paroxysm of
coughing, and a considerable quantity of pus
was expectorated.

We felt that we were at fault in this case,
because we did not attach more importance
to the pulmonary findings. Due considera-
tion of the oblique findings would have re-
sulted in a very different method of
treatment.

Case III. Mr. C, age seventy, with a his-
tory of pneumonia which did not clear up
within the usual period. Radiographic study
of the chest in the standard positions dem-
onstrated a small amount of fluid in the
lower right. Again, the symptoms were out
of proportion to the findings, and the oblique
method of study revealed lower lobe path-
olog\-. in addition to the small amount of
fluid.

At the time of operation, when die pleural
ca\ity was opened, there was escape of a
thin, sanguineous fluid, and not until the
lung itself was entered was pus obtained.

A third area in the chest obscured by
anatomic structures is the space between the
heart and the posterior chest wall. Internists
have frequentl)' t|uestioned the interpreta-
tion of chest findings in a given case, inquir-
ing as to the possibility of a pulmonary
lesion being obscured by the heart shadow.
Our experience with Case IV of this series
will serve to emphasize the need of having
in mind the possibility of collections of fluid
which can be obscured by the heart, the heart
in the meantime .showing no displacement.

Case IV. Mr. H., age twenty-six, post-
influenzal pathology. The anteroposterior
plate showed slight impairment of density
over the lower left lung field, with a visible
left leaf of the diaphragm and no displace-
ment of the mediastinal shadows. In spite of

Lateral and Oblique Studies of the Chest

III

our negative report for the presence of any
quantity of fluid in the left pleural cavity, a
thoracotomy was performed and a pint or
more of pus was evacuated. In this case, also,
we believe that thorough lateral and oblique
studies would have revealed this collection
of fluid.

DISCUSSION

Dr. Kennon DuNiiAiM. I wish to thank Dr.
Evans for bringing to our attention again the
necessity for as complete an examination of
the chest by the ^-ray as is possible. I am sure
that he does not mean that we should give up
the ordinary stereoscopic postero-anterior ex-

FiG. g. Case v. Posteuo-anteriok Plate of ax
Adult's Chest Showing Elevation and Distok-
Tiox OF THE Right Leaf of the Diaphragm.

CONCLUSIONS

1 am well aware that the above procedure
in the examination of the chest is carried on
by many workers. My object in presenting
it at this time is to emphasize the necessity
for a more frequent variation from the
standard positions.

The mere reporting of a small amount of
fluid in the lower pleural cavity is of no
practical value in many chest conditions, for
the presence of the fluid is merely incidental
to the basic pathology, which is pulmonary.

As regards juvenile tuberculosis, the wide
divergence of opinion regarding the mode of
infection and the distribution of lesions indi-
cates the necessitv for immediate and wide
promulgation of the views held by roent-
genologists w^ho are familiar with the type
and location of visible lesions of tuberculosis.

Fig. id. Case v. Lateral Pl.vte of the Chest Shows
Adhesions Involving the Diaphragm well In-
terior, the Posterior Surface is Clear.

This plate shows graphically the extent of the
pulmonary area which is obscured by the ordinaiy
postero-anterior plate.

posures from which we gain so much, but he
does mean, or at least I think he means, that
that is not alwa}s sufficient, and it is of utmost
importance that every aid should be given to
determining these lung tumors. For years .r-ray
men have been working in the lung field, and
ha\e had aliuost no encouragement from the
medical profession. The war changed that.
They are coming to }0u and to me to help them
solve their chest problems. Just as in Dr. Stew-
art's work, the bronchoscopist is absolutely de-
pendent on the ,r-ray examination. Now, when
we have made an examination, don't let us stop
because we are in a hurry. Don't let us get

112

Simple and Rapid Hardening of Gas Tubes

into a hurry which may cause us to lose an
important phase of an examination.

Before I sit down, I simply wish to impress
on you that wherever it is possible, please im-
press upon your clinician that the aid of the
x-va.}- is not only necessary in cases they think
are important; the great importance of the
.t'-ray examination of the chest is where they
do not have sufficient physical signs to explain
the case. The greatest benefit we have re-
ceived from the .r-ray examination has been
where it has been done routinely. Every case
coming to a hospital should be examined, and
til at is where ^•ou get Aour beautiful results

and most illuminating work. It helps the clini-
cian and then, for the first time in the clini-
cian's life, he wakens up to the fact that his
physical examination has its limitations just as
the .r-ray examination has its limitations.

But this method of Dr. Evans' impresses on
us the value of the lateral and oblique expo-
sures of the root of the lung, and possesses
inestimable value. The stereoscopic plate be-
comes helpless in front of an absolute density.
\\"e cannot stereoscope heavy densities — we do
not stereoscope the heart, but they must be
studied, and to do this we must find a way.
Dr. Evans has shown the wav.

A SIMPLE AND PRACTICAL METHOD FOR THE
RAPID HARDENING OF GAS TUBES

By SIDNEY H. LE\'Y, AI.D., and HUBERT MANX, M.D.
Roentgen Ray Department, ^.lount Sinai Hospital

XEW YORK CITY

A T the present time there are three rec-
^ ^ ognized methods of hardening gas
tubes which have become too soft for use:

1. Tubes may be hardened by setting them
aside and allowing them to rest for an in-
definite period.

2. Tubes may be hardened by passing a
weak current through them for several min-
utes, either through the true or through the
accessory anode. The current must pass
through the tube until the tube is hot.

3. Tubes may be hardened by being re-
pumped at the factory. The first two meth-
ods are time-consuming and unreliable:, fail-
ing completely in the case of very soft tubes.
The third method is time-consuming, incon-
venient and expensive.

The possibility of hardening .r-ray tubes
rapidly and conveniently by cooling the soft-
ening device with an ethyl-chloride spray or
other means suggested itself on theoretical
grounds. The efficacy of the method has been
demonstrated by the successful hardening of
twenty-five different gas tubes. Up to the
time of publication fifty tubes have been

succes fully hardened. After a short discus-
sion of theoretical considerations we shall
give in detail our practical methods and
results.

THEORETICAL COXSIDERATIOXS

The fact that gas tubes become harder on
standing suggests the occurrence of con-
densation and absorption or adsorption of
gas bv the tube wall, anode or softening de-
vice, and particularly the condensation and
absorption of water vapor. The experimental
work which resulted in the production of
high-vacuum Coolidge tubes taught us that
the orditiary low-vacuum tube contains a con-
siderable amount of water vapor. The con-
struction of the ordinary softening device,
which consists of some hygroscopic material,
such as asbestos packing so placed that it can
be heated bv the electric current, leads us to
believe that the softening of the tube con-
sists generally in the liberation of water
vapor and that the hardening which takes
place on standing is mainly due to the re-
sorption of the water vapor previously lib-

Simple and Rapid Hardening of Gas Tubes

erated. While the condition of the tube wall
and that of the anode and cathode are un-
doubtedly factors in the state of hardness of
the tube, it is probable that most of the re-
sorption takes place in the softening device
which, because of its relatively large surface
and hygroscopic character, is best adapted
for this function.

The avidity with which finely divided sub-
stances, such as animal charcoal, absorb
gases when cooled to a very low tempera-
ture, as by lif|uid air, suggests the possibility
of hastening the resorption of gas or water
vapor in a gas tube by cooling the softening
device. The rapid fall in vajior tension of
water with fall of temperature suggests that
the use of even a mild cooling device, such
as the eth}-l-chloride spray, will be fairly
efficacious in causing condensation or in-
creased concentration of water vapor in the
cool part of the tube and hence increased
resorption and consefpiently increased ex-
haustion or hardness. These theoretical con-
siderations are borne out by the practical
results which follow.

PRACTICAL METHOD AND RESULTS

The actual method of hardening the tube
is as follows:

1. Current is passed through the tube
until it becomes fairly hot.

2. The softening device of the x-ray tube
is sprayed slowly with ethyl-chloride. From
thirty to fifty grams is generally sufficient,
and during the spraying a coating of snow
and ice should collect on the glass bulb of the
softening device. It is advisable to protect
the bulb of the tube with a towel, exposing
only the chamber containing the softening
device. A thin layer of absorbent cotton held
down by two or three rubber bands placed
around the tube wall containing the soften-
ing device facilitates the spraying of ethyl
chloride. By this method none of the ethyl
chloride is wasted or lost and the formation
of snow and ice is hastened.

3. Allow the tube to stand five minute.
Dry the tube thoroughly. An electric fan
aids in cooline: the softening: device durine:

the spraying, and also later in drving the
chamber containing the softening device.

4. Reheat the tube by passing the current
through the anticathode or accessory anode.
,\fter this procedure it is generally found
that the tube is harder than before and be-
comes progressively harder for about
twenty-four to forty-eight hours. Different
tubes vary in the ease with which they are
hardened ; some require only one treatment
and others several repetitions of the treat-
ment. Once the spark-gap has begun to in-
crease it is easy to increase the hardness of
the tube to any desired degree by repetition
of the above treatment.

On the following page will be found a
table containing a list of twenty-five tubes
rehardened by this method.

SUMMARV

As a result of our experiments with
twenty-five gas tubes of several different
tvpes, we wish to emphasize several points
which will be useful to any one employing
this procedure. It makes very little differ-
ence whether the asbestos packing in the
softening device is in direct contact with
the outer glass wall or is contained in a sep-
arate tube. In general older and more highly
seasoned tubes require more preliminary
heating and respond to treatment more
slowly than do newer tubes. The reason for
this is that the tube must be heated suffici-
entl}' to drive particles of gas from the metal
parts and glass wall into the bulb so as to
allow this gas to be absorbed by the soften-
ing material. Several treatments ma}' be
necessary, but once the spark gap has begun
to increase it is a simple matter to attain
anv degree of desired hardness. Frequently
it will be found that tubes will show almost
no change immediately after treatment but
become much harder from one to twenty-
four hours after. If at the end of twelve to
twenty- four hours the tube does not tend to
become harder, another treatment is indi-
cated. Tubes hardened by this method will
keep their vacuum and gap indefinitely, as
shown bv their dailv use in the .r-rav labora-

114

Simple and Rapid Hardening of Gas Tubes

tory of Mount Sinai Hospital, New York
City. The tendency of these tubes upon
standing is to become progressively harder.
We have not had experience with tubes
containing metallic regulators as softening
devices, therefore cannot state whether this
method is applicable to such tubes. Our ex-
perience has been limited to tubes containing
hygroscopic material.

COXCLUSION

In conclusion, we feel that both theoretical
considerations and practical results justify
us in stating that gas tubes containing some
hygroscopic material such as asbestos pack-
ing can be hardened rapidly and conveniently
by cooling the softening device by an ethyl-
chloride spray.

TABLE I

SPARK G.'\P

SPARK GAP

SPARK GAP ONE

24 HOURS

48 HOURS

SPARK GAP BEFORE

HOUR AFTER

AFTER

tub:

E HARDENIXG

H.\RDEXING

HARDENING

REMARKS

Less than 2 in.

3 inches

inches

7 inches

Soft since 1916

Less than 2 in.

Xo change

inches

■jYi inches

Soft since 1916

Less than 2 in.

No change

inches

6 inches

Soft since 1916

Less than 2 in.

3 inches

inches

63/2 inches

2 inches

5 inches

inches

7 inches

Helium
Accidentally

Less than 2 in.

4 inches

inches

8 inches

Softened. Re-
\ turned
( quickly

2 inches

3 inches

inches

5 inches

Helium

^Less than 2 in.

Xo change

2Ya

inches*

5 inches

2 inches

Xo change

AY2

inches

4Y2 inches

Less than 2 in.

3 inches

3/2

inches

5 inches

Less than 2 in.

4 inches

5/2

inches

5^ inches

( Old target.
1 Focal spot
t- cracked.

2j/2 inches

zYz inches

inches*

7Y2 inches

Less than 2 in.

2 inches*

inches

6 inches

Less than 2 in.

2'Y inches

inches

6 inches

2^4 inches

Xo change*

inches

SYi inches

2Y4 inches

4 inches

inches

7 inches

4 inches

5 inches

5/2

inches

5J/2 inches

5 inches

SY2 inches

dYi

inches

6Y2 inches

Less than 2 in.

2 inches

4/2

inches

5 inches

Less than 2 in.

6 inches

6/2

inches

6Y2 inches

Less than 2 in.

Xo change*

inches*

4 inches

2 inches

X^o change*

3/2

inches*

7 inches

4I/2 inches

55/2 inches

tY2

inches

7Y2 inches

Less than 2 in.

Xo change*

change*

4Y2 inches

2Ya inches

2Ya inches
testing tube.

3/2

inches

6 inches

*Denotes re-spraying after

REMARKS ON THE TECHNIQUE OF THE ROENTGEN
EXAMINATION OF THE KIDNEYS

By W. S. LAWRENCE, M.D.

Instructor in Roentgenology, University of Tennessee, Knoxville

MEMPHIS, TENNESSEE

^ I "* HE technique which I am about to set
■*■ forth in more or less laborious detail is
by no means all my own. if indeed I can lay
claim to any of it. It is mostly patched to-
gether from the oft-repeated suggestions of

that can be achieved when this work is done
in the right way. *

In doing kidney work our chief aim should
be to produce plates showing the whole kid-
ney outline clearly, unmistakably and with-

FiG. I. Normal Kidney — Right. Xote Calices Uninjected.

Others. The only justification for the use of
the little word "my" which frequently sets
the rest of us on edge, is a certain grouping
of the essential and indispensable factors of
success, an exacting and persistent carrying
out of every detail, together with full knowl-
edge of, and an abiding faith in, the results

out the aid of the imagination. Such a plate
will possess the maximum of diagnostic
value in every condition for which we are
called upon to examine the kidneys. If the
kidney substance shows clearly, denser sub-
stances will show much more clearly.

To make such plates with uniformity and

115

ii6

Technique of Roentgen Examination of Kidneys

certainty there are certain points of tech-
nicjue which are absohitely essential. I will
mention them somewhat in the order of their
importance, though after the first, there is
little choice as to which should be placed
second, third or fourth in order of import-
ance. Easily of first importance is the cjuality
of the rav used ; second, correct and adecjuate

and an exposure varying from four to eight
seconds depending upon the size of the pa-
tient. The time only is varied.

Second in importance and very much more
difficult to obtain are proper compression of
the patient and correct placing of the com-
pression cylinder. For accurac}^ and ease of
manipulation it is almost essential that the

Fig. 2. Normal Kidney Outline — Left Kidney.

compression; third, preparation of the pa-
tient; fourth, control, real control, of the pa-
tient's respiration.

Kidney plates should be clear, soft and
sharp, suggesting under-exposure rather
than over-exposure. No black should any-
where appear on the plate. Such a plate can-
not be made if the tube is excited by a cur-
rent of high voltage. In actual practice I use
^ 3 to 3^ inch spark gap, 35 milliamperes.

tube-stand be attached to the table, moving
freely and easily at the side. With this type
of table the tube-stand can be fixed so rigid
that there is no possibility of any movement
of the patient altering the position or angle
of the tube. It is cjuite essential that the end
of the compression cylinder be ec^uipped with
a convex aluminum cap. This sinks deep into
the soft parts and displaces denser material ;
it also sometimes forces aside gas which may

Technique of Roentgen Examination of Kidneys

117

be present in the colon. If the diameter of
the cylinder is more than 5 inches at a dis-
tance of 13 inches from the target, the plate
will be very little clearer than if no cylinder
at all were used.

Again, in practice, I proceed as follows:
The patient's knees are flexed. An 8 by 10
plate is placed crosswise under, sav. the right

raised. The cylinder is now tilted about 10 to
25 degrees to point up under the ribs, and
fixed in this position, and pushed up under
the ribs as far toward the patient's head as
he will allow, and fixed in this position. Fin-
ally, the tube and cylinder, sliding on the
horizontal arm of the tube-stand, are moved
as far towards the right as the patient will

Fig. 3. XoRMAL Kidney Sh.\dow — Left.

side, so that its lower edge is about even with
the umbilicus. The tube is then adjusted over
a point midway between the umbilicus ?nd
the ensiform cartilage. The cylinder is then
tilted between 5° and 10°, so as to point to-
ward the right. At this angle it is lowered
onto the patient slightly to the right of the
median line, brought down with a fine ad-
justment device as tight as the patient w'U
easily allows and fixed so that it cannot be

allow, and fixed in this position. This last
movement will pull the ribs over to a con-
siderable degree and it is necessary to in-
struct the patient not to turn toward the
right side, and not to allow his back to slip
on the table with an inclination to follow the
movement of the tube. With everything fixed
and rigid, the exposure is made.

While the preparation of the patient is
important, it is not essential in every case.

ii8

Technique of Roentgen Examination of Kidneys

In patients who are not constipated or sub-
ject to gas formation in the colon, the exam-
ination may be made successfully without
previous preparation; however, it is best in
every case, when circumstances permit. This
preparation consists of a thorough laxative
the night before and an enema, as nearly as
convenient, immediately preceding the exam-

In such a case we have an ample bed of
perinephritic fat much less dense than the
kidney substance and supplying the contrast
that is so desirable. For this reason even
large, fat patients often prove easier than
small, lean ones. But, large or small, fat or
lean, the kidney outline can be brought out.
It has been customary to dismiss the point

Fig. 4. Kidney Injected — Catheter in situ. Note the Blurring
Effect of Incomplete Respiratory Control.

ination. The importance of this cannot be too
strongly emphasized in many cases. The kid-
ney outline cannot be clearly brought out if
there is a big gas pocket in the colon imme-
diately over it.

In this connection a word as to the kind
of patient who is most favorable for this
work might not be amiss. The most favor-
able type is the rather fat, small individual.

of the patient's respiration simply by say-
ing, "instruct the patient to hold his breath
during the exposure." If the doing were as
easy as the saying, it would need no further
comment, but it is not. Many patients find it
c[uite difficult to stop breathing entirely, even
for five or six seconds. Many think that they
are holding their breath when they are not.
Place a mirror on the abdomen of such a

Technique of Roentgen Examination of Kidneys

119

patient, and while he is trying to hold his
breath the reflection from the mirror will
continue to sweep back and forth upon the
ceiling. Such patients need instruction in
holding the breath and close watching during
the exposure.

The kidneys move more than we realize

during respiration. This movement is from
one-half to one and a half inches. A move-
ment of only one-quarter inch will convert
the shadow of a round stone into a long one,
cause us to miss a small stone entirelv, and
completely obliterate any well-defined kidney
outline.

Fig. 5. Kidney Outline, with Stone in Lower Poll. Catheter in situ. Note the Sharpness of
THE Catheter Shadow, Indicating Complete Respiratory Control.

SUBPHRENIC PNEUMOPERITONEUM*

Produced by Ixtra-uterixe Ixsufflatiox of Oxygen as a Test of Patency of the
Fallopian Tubes in Sterility and in Allied Gynecological Conditions

By I. C. RUBIN, ^I.D., F.A.C.S.

NEW YORK CITY

' I ""HE production of pneiimoperitoneuni
-■- by the method of insufflating the
uterus \Yith oxygen is intended to serYe the
specific purpose of testing the patency of
Fallopian tubes. When the tubes are patent
the gas passes into the peritoneal caYity, es-
tablishing an artificial pneumoperitoneum.
This is detected by fluoroscopic examina-
tion. When occluded, the gas fails to reach
the peritoneal caYity. In this failure to es-
tablish a pneumoperitoneum 1)y the uterine
route is furnished a fact of diagnostic Yalue
important particularly in the problem of the
sterile woman.

Comparison of the Ahdoniiiial and Uter-
ine Method of Prodneing Pnenmoperi-
toneuni. — This method cannot enter into
competition \Yith the production of pneumo-
peritoneum by abdominal puncture because
of certain natural and pathological limita-
tions. I.' It is obYiously limited to women.
2. It is not applicable to all women, par-
ticularly the unmarried. Conditions such as
pregnancY, menstruation and pehic inflam-
mation contraindicate for the time being its
use. The method by abdominal puncture
maY be employed in the presence of nearly
all these conditions without regard to uter-
ine function. In cases where the uterus may
be properly insufflated and the tubes are
patent, it is of course possible to fill the
peritoneal caYit>' with any desirable cpan-
titY of oxygen, in which case it may also
serYe as an aid in general abdominal diag-
nosis. This I haYe done in scYeral cases at
the request of colleagues in the medical and
surgical serYices of Alt. Sinai Hospital. It
maY ouIy be mentioned here that it can be
done YcrY simply without occasioning any
appreciable sense of discomfort to the pa-

*Read at the Twenty-first .^nnual Meeting of The .\merican Roextgen Ray Society, Minneapolis, Minn

1 20

tient and inYoh'es no special surgical expe-
rience. It is not. my purpose to adYOcate it
either to substitute or to supplant the ab-
dominal puncture method for general ab-
dominal diagnosis. I am interested chiefly
and practically in the aid it may render in
clearing up the etiolc:)gy of sterility in
women.

In the problem of sterility a negatiYe re-
sult is of ecjual importance with a positive
result. Both prognosis and therapy depend
upon whether Fallopian tubes in any given
case of sterility are open or closed. I have
elsewhere^ pointed out that if we could
demonstrate beforehand that the tubes are
occluded a great many operations on the cer-
vix of the uterus would not be undertaken.
Instead of operating in such case upon the
lower end of the uterus with a fruitless re-
sult, the patient remaining sterile and hop-
ing against hope of becoming a mother,
proper therapy would consist in immediately
opening the abdomen with the object of
freeing the tubes and doing some adequate
plastic operation. Such operations have not
infrequently resulted in curing sterility.
Wliether or not this type of operation is
consented to, we are at least in the position
to tell the patient from the very outset what
her chances are for becoming a mother.
■Much time may be saved for those women
who would gladly submit to a corrective
operation at the very beginning were we in a
positicm to locate the obstacle to conception
at the true portion of the genital canal.

A word as to the limitation of the ahdoni-

'^Jonnial American Medical Association, Sept. 4,
1020. Paper read before the Section of Obstetrics
and Gynecology at the seventy-first session of the
American Medical Association.

Sept. 14-17, 1920.

Subphrenic Pneumoperitoneum by Insufflation of Oxygen

121

iiial puncture fuetlwd and its ability to dem-
onstrate patency or occlusion of the tubes.
It has been possible to outHne the uterus,
tubes and ovaries, inckisive of tumors of
these organs and inflammatory conditions in
the pelvis, bv forcing the ox\'gen through
the abdominal puncture into the pelvis in
the extreme Trendelenburg posture. In a
very limited number of instances one may
be fortunate enough to succeed by this
method in demonstrating the fimbriated end
of both tu1)es distinct from the ovaries and
the uterus. In the abscence of adhesions one
might assume them to be normal. In the
presence of tumor masses it is not so easy to
distinguish between the tube and ovaries,
nor are we always fortunate enough in
separating the shadows of distorted and dis-
located tubes from adherent and overlying
ovarian timiors, or from pehic abscesses
and tumors of the uterus. One need but re-
call in this connection the difficulty of dis-
tinguishing structures in pelvic inflamma-
tions w^ien the abdomen is opened. Also the
demonstration of bilateral masses by the
shadowgram does not preclude actual pat-
ency of one or both tubes. It is absolutely
possible to determine this fact by the method
of intra-uterine insufflation of oxygen. I
have on several occasions been able to dem-
onstrate patency of the tubes in the presence
of bilateral adnexal masses and at the same
time establish that the lesion involved the
ovaries alone. If in the presence of pelvic
masses the gas fails to produce a pneumo-
peiitoneum it may be safely concluded that
the tubes are diseased and occluded at some
point of their lumen.

Whether or not gross lesions in the pelvis
may be more accurately outlined and inter-
preted by pneumoroentgenograms than by
physical examination, the matter of patency
or non-patency is specifically established by
the patency of the tubes to oxygen. This
point has hitherto been a matter of clinical
speculation defying the skill of the expert
in physical examination. The only way by
which this fact could formerly be established
was by actual laparotomy with inspection of

the tubes, palpation, probing them with a
sound and inflating them from the fimbri-
ated end, a practice advocated notably by
English gynecologists.

The value of the method as .a practical
test in cases of sterility may perhaps be il-
lustrated by the following two cases".

Case I. A patient married three years and
sterile ; upon pelvic examination she was ad-
vised to be operated, and a dilatation of the
cervix, curettage and stem pessarv insertion
were subsequently performed. Four days
following this operation I was recpiested to
test the patenc}' of her Fallopian tubes. The
method emplo}'ed b)' me resulted in failure
to establish a pneumoperitoneiun. Laparot-
omy the same day revealed the fact that
both tubes were closed at the fimbriated end.
They were only slightly distended, their
walls were flaccid and they were siU"rounded
by soft, cobweb adhesions — in other words
an old standing bilateral hydrosalpinx. The
operation on the cervix in this case was cer-
tainly fruitless and could have been avoided
by a preliminary examination with oxygen.

Case II. A patient married five years,
sterile, no pelvic lesion demonstrable to ac-
count for the sterility. Insufflation of the
uterus with oxygen on three occasions (with
and without pressure control ) failed to estab-
lish a pneumoperitoneum. She was advised
to have a laparotomy performed in the en-
deavor to remedy the occlusion. This advice
she apparently did not heed because some
months later she had a curettage and Dudley
operation, following the advice of a physi-
cian who assured her that to become a
mother all she needed was to have her womb
"stretched." The lesion in her case could not
have been very pronounced at any time,
eluding detection by the palpating finger, be-
cause the operation was performed by a
gynecologist of considerable experience and
one who must have concurred in the opinion
of the general practitioner.

Safety of the Method and Advantages
Over Exploratory Laparotomy. — Notwith-

122

Subphrenic Pneumoperitoneum by Insufflation of Oxygen

standing theoretical objections, all of which
I have carefully considered in first contem-
plating the method, it has proved in my
hands an absoluteh* safe procedure. Thus
far I have had occasion to employ the
method in 150 cases. As some of the cases
were re-examined for purposes of corrobor-
ation, the total number of examinations
was 170. In no case was there any evidence
of injury or of infection. The cases were all
observed carefully for a period of several
months.

Compared to an exploratory laparotomy
for the specific purpose of determining the
patency of Fallopian tubes, it has several
superior advantages, not the least of which
is the economic advantage of saving the pa-
tient from the usual period required for
post-operative convalescence. The method
may be employed as a routine measure in
one's office and the patient loses no time in
laying up, has none of the discomforts and
morbidity attendant upon a laparotomy. I
am not discussing the question of mortality,
assuming that that is practically nil in ex-
ploratory surgery. The method proposed by
me should never result in mortality. The one
theoretical possibility of fatality resulting is
offered by the occurrence of embolism. This
I have satisfied myself, by experimentation
upon the extirpated uterus and in the living
animal bv direct intravenous insufflation of
oxvP'en. can be dismissed from practical
consideration. This accident and that of in-
fection have not occurred in my series of
cases, and infection should never occur
when the procedure is adopted in properly
selected cases and for the specific object of
testing the patency of Fallopian tubes.

Contraindications. — The uterus should
not be insufflated with oxygen in the pres-
ence of pus pouring down from the cervix,
in the presence of fever caused by pelvic
inflammation, in the presence of acute bar-
tholinitis, urethritis or vaginitis. It is not ad-
visable to use it during menstruation or any
irregular uterine bleeding.

Ideal to be Sought in the Use of the
Method. — By this I mean that w-e should be
able to emplov it in the office as a routine

procedure for diagnosis comparable to
cystoscopy and ureteral catheterization, oc-
casioning no more and possibly less pain and
discomfort than obtains in the urological
examination. One of the chief aims is to
make the method tolerable to the patient. It
should not require the use of an anesthetic.
So far I have not had to resort to any. It
should take a short time, a minute or two,
at the most three. It should be follow-ed by
very slight symptoms and not interfere with
the daily duties and usefulness of the pa-
tient. To accomplish this, it is necessary to
produce what might lie called a miniature
pneumoperitoneum confined in the erect
posture to the subphrenic space. The small-
est amount of oxygen sufficient to show dis-
tinctly through the fluoroscope should be in-
jected. I have found in developing the
method that from 100 to 150 c.c. of oxygen
suffice to establish the subphrenic pneumo-
peritoneum. The most favorable time for the
test is in the post-menstrual stage, in the in-
terval of apparent functional quiescence.

Technique. — The armamentorium con-
sists of an oxvgen tank connected w'ith a
water bottle, the rubber stopper of which is
perforated at three points through which
bent glass connecting tubes pass. (Fig. i.)
One of these glass tubes is connected di-
rectly with the oxygen tank and dips down
below the water level. The two other p-lass
tubes dip down one or two inches and do not
reach the water level. One of these is at-
tached by rubber tubing to a mercurial
manometer and the other is attached in the
same way to the metal cannula. This metal
cannula is of the Keyes-Ultzman type and is
perforated at the tip by several small aper-
tures. (Fig. I.) A single tenaculum or bullet
forceps, a uterine sound, a dressing forceps
and bivalve vaginal speculum complete the
apparatus. A rubber urethral tip is fitted
over the metallic cannula to a point i ^ to 2
inches away from the cannula tip.^

^Recently at the suggestion of my friend Dr. E. D.
Oppenhcimer I have adopted a simple device for
measuring the voKime of the gas and hope to de-
scribe it in the near future. It is made by courtesy of
\\'allace & Tiernan, 349 Broadway, New York City.

Subphrenic Pneunioperitoneuni by Insufflation of Oxygen

12"

The voKime of gas entering the uterus
and eventually into the peritoneal cavity
may be measured by displacing water and
taking the time — interval measured in min-
utes. The average amount of water dis-
placed should not exceed 250 c.c. per minute
nor be less than 50 c.c. per minute. The rate
of flow determines the pressure. The rapid-
itv with which this rises I have found to be
best limited to a 10:15 second interval for
100 millimeters mercury. At this rate from
approximately 250 to 150 c.c. of oxygen is
released per minute. This is determined pre-
viously by pinching the rubber tubing with
the needle valve shut, allowing the gas to
pass through at the rate fixed by the water
displacement. With the gas flowing at this
rate it may now be introduced into the
uterus. The cervix is wiped clean and
painted with iodine. A single tenaculum
hook grasps the anterior lip. The cannula is
introduced into the uterus well alcove the in-
ternal OS and the urethral rubber tip is
pushed well into the external os so as to ren-
der it air-tight. The gas is allowed to escape
during this maneuver through the needle-
valve release ; the pressure is therefore at-
mospheric. As soon as the cannula is well
secured within the uterus the needle valve is
closed, allowing the oxygen to be insufflated
within the uterus. Almost instantlv the pres-
sure rises. When the cannula is fixed within
the uterus the patient is raised in slight
Trendelenburg position and the vagina is
filled partly with water to show any escap-
ing gas from the cervix. This is not always
necessary and should only be done in doubt-
ful cases.

Pressure Reading in the Case of Patent
Tubes. — The mercurial pressure rises to at
least 40 mm., more often to from 60 to 100,
with a slight momentary fluctuation possibly
at that point, when it drops cjuite sharply 20
to 40 or even 60 points, which latter level it
maintains more or less until the cannula is
removed. The time required for the pressure
to reach its maximum point according to
the recommendation as above described is
usually 15 to 25 or 30 seconds. The rest of
the time, say 30 seconds to 45 or 60 seconds,

is allowed for actual inflow into the peri-
toneal cavity.^ This will depend upon the
time interval recjuired for the initial rise to
the maximum on the one hand and on the
other upon the size of the individual.

If the individual is narrow-waisted and
thin she does not require as much gas to
produce the subphrenic pneumoperitoneum
as would an ample- waisted patient. These

Fk;. I. 'J"nK APPARATUS Assembled. Note the Relief
(Xeedle) Valve. This relief valve may be at any
point in the outlet tube in case the tj'cos type of
manometer is emploj'ed.

matters one can learn to gauge after some
experience. No hard and fast rule can be
laid down for these variations. At most they
are slight and offer no difficulty. The aver-
age amount of oxygen required in a thin
individual is from 75 to 100 c.c. In a stout
woman it is well to use from 150 to 250 c.c*
Pressure Reading in the Case of the Non-

3The siphon meter of the Wallace & Tiernan type
records the volume passing through automatically.

■^W'hen CO; is employed the quantity may because
of its rapid absorption exceed these figures several
fold.

124

Subphrenic Pneumoperitoneum by Insufflation of Oxygen

Patent Tubes. — The pressure rises steadily,
reaching 200 within 30 to 45 or 60 seconds.
The pressure should not be allowed to ex-
ceed 250. It is maintained at between 200
and 250 for at least another minute if pos-
sil)le. This can be done by regulating the
needle valve to permit a slight escape of the
gas. In my experience so far a pressure of
200 or mo-re, provided the rate of flow does

Symptoms, i. During the Oxygen Insuf-
flation.— The introduction of the cannula is
attended in most cases with slight pain.
Grasping the anterior lip of the cervix by
the single tenaculum hook is noticed
scarcely, if at all, by the patient. The actual
insufflation in the patent cases seldom causes
pain. When the initial pressure exceeds 100
the patient may complain of a sensation of

Fig. 2. Subphrenic Pneumoperitoneum. 250 c.c. or
Oxygen Insufflated throuc.h the Uterus and
FALLOPI.A.N Tubes. Diaphragm distinct on the right
side; not visilile on the left.

not exceed 250 c.c. per minute, proves
fairly conclusively the presence of tubal ob-
struction. This may of course be within the
uterus itself, the blockade being at the
uterine ostiae of the tubes, or it may be at
any point along their lumen. When the rate
of flow exceeds 250 c.c. per minute the
initial rise may occasionally read 200 mm.
or more before the gas passes into the Fallo-
pian tubes and thence into the peritoneal
cavity. The physics thus expressed is only
from practical tests. Exact computations
have as vet not been made.

Fir,. 3. Subphrenic Pneumoperitoneum. 1500 c.c. of
Oxygen Insufflated through the Uterus and
Fallopian Tubes. Diaphragm distinctly visible on
right and left sides. Abdominal viscera displaced to
a considerable depth. For the purpose of demon-
strating patency of the Fallopian tubes one-fifteenth
of this amount is sutificient and satisfactory in the
majority of cases.

fullness or bearing down or occasionally she
may feel as if she were unwell. In the non-
patent cases with the pressure rising to 200,
cramps are occasionally complained of, now
in the suprapubic region and now in one or
both sides. Since the time required for insuf-
flation is the short interval of one or two
minutes, practically every case can tolerate
it. I have had practically no failure due to
intolerance during- the examination. A ner-

Subphrenic Pneumoperit(3neum by Insufflation of Ox}gen

125

yous patient will sometimes defeat the com-
pletion of the test, but even she can l)e reas-
sured and will submit to it at another time.
That will happen once in 50 or 100 times.

2. After the Oxygen Insufflation; Fluor-
oscopx. In the Patent Cases. — Inasmuch as
the patient is instructed to stand up immedi-
ately on withdrawing the uterine cannula,
the oxygen gas rises almost instantaneously
to the region of the diaphragm. It occupies
the sul)phrenic space for a depth of Vj to i
inch or more depending upon the auKtunt
insufflated. (Fig. 2.) Within two or three
minutes if not sooner (just as soon as the
patient can be set up before the fluoroscopic
screen) the transparent "gas" area may be
seen under the diaphragm. The liver on the
right side is seen displaced in a downward
direction. Not infrequently the gas may be
localized to one or the other side, but as a
rule the diaphragm may be seen lifted above
the underlying abdominal viscera from right
to left. It is discernible as a transverse sep-
tum and is unmistakable. When the sul>
phrenic pneumoperitoneum is not at once
visible the patient is instructed to lie (jn her
right or left side for a few minutes, after
which the gas will show clearly on one side
or the other.

It is not necessary for the purpose of test-
ing the paten-y of Fallopian tubes to fill the
peritoneal ca\'ity with a large volume of gas
in sufficient quantity to "visualize" the ab-
dominal viscera, as in Figure 3. The symp-
toms in such a case are rather distressing and
this is obviated by reducing the pneumo-
peritoneum to its diminutive. With 75 to
100 c.c. of oxygen under the diaphragm the
secondary symptoms are almost negligible.
Slight sticking pains between the shoulder-
blades or in the shoulders themselves are
noticed by the patients. There is no abdom-
inal distress, and if at all present it amounts
to a slight sense of discomfort about the dia-
phragm. The vast majoritv of the patients
leave the office and continue in their ordi-
nary daily routine. Some patients may re-
quire to lie down with feet elevated for a
few hours. As, according to Alvarez, carbon

Fir.. 4. A BicoRxcATE Uterus. Thorium injection.
The lulies are closed liy a hgature at the fimbriated
end. Xote the definite ckibbed outline of the tube
at point of ligature and the narrow caliber of the
intramural portion.

Fig. 5. The S.\me Specimen' as ix Figure .1. Skia-
graphed during thorium injection with the ligature
removed allowing the solution to escape throu.gh
the fimbria. Xote the irregular and overlying
shadows.

Fig. 6. Skiagraph of the Same Specimex as ix
Figures 4 axd 5. Oxygen injection. Xote the faint
shadows in the horns of the uterus and the absence
of anv contrast shadows within the Fallopian tubes.

126

Subphrenic Pneumoperitoneum by Insufflation of Oxygen

dioxide gas is more rapidly absorbed than
oxygen, it may be well to use it and reduce
the secondary symptoms to a negligible
minimum.

Immediately on withdrawing the uterine
cannula there may be a slight regurgitation
of oxygen with a slight oozing of several
drops of blood that is readily checked by a
sponge applied to the cervix. It is negligible
and gives no further trouble. By selecting

in the non-patent cases to check up the find-
ings at the first examination. With the ap-
paratus properly adjusted in each case the
findings will be found to corroborate each
other at the second test. Occasionally, how-
ever, there may be an error in technique
which will invalidate the conclusion. Most
scrupulous attention should be given the
possible points of leakage along the entire
apparatus.

Fig. 7. Case of Ablated Tubes; Large Uterus — 40 Fig. 8. Same Case as in Figure 7. 40 c.c. Thorium
c.c. OF Oxygen Injected into the Uterine Cavity. Injected into the Uterine Cavity.

This is seen transversely pear-shaped. The specu-
him, cannula and Thomas pessary are also seen.

the post-menstrual period for the test one
can avoid even this slight oozing.

In the Non-Patent Cases. — Beyond the
temporary discomfort produced by the in-
sufflation there are no further symptoms.
The cramps may continue for a minute or
two or perhaps five and then subside. None
of the referred shoulder pains are com-
plained of and there is no epigastric oppres-
sion. The oozing is almost as slight as in the
case of patent tubes; the oxygen regurgita-
tion may be more evident. The non-patent
tube cases are perfectly comfortable after
the test and leave the office to go about their
duties as freely as before.

It is well to mention here that I have
made it a rule to repeat the test at least once

While in the positively patent cases there
may have been some regurgitation, never-
theless when this occurs and the gas does
not enter the peritoneal cavity we are left in
doubt and must, if need be, repeat the test
several times. If regurgitation takes place
each time it is highly probable that there is
an obstruction within the uterus which is
responsible for it. On the other hand, oxy-
gen may escape from the cervix and a suf-
ficient quantity nevertheless reach the peri-
toneal cavit}' as may be determined by the
fluoroscope.

Anatomical Consideration in Relation to
the Test. — The ideal case for the test is one
in which there is no thick tenacious plug
present, in which the external os is round

Subphrenic Pneumoperitoneum by Insufflation of Oxygen

127

and intact, the uterus not sharply angulated.
In such cases the cannula (ordinary size)
enters easily and obturation is more perfect.
When the uterus is sharply flexed forward
or backward it is necessary to shape the can-
nula accordingly so that it may enter the
uterine cavity to a point above the internal
OS. When the external os is gaping and torn
as obtains in certain cases of relative or sec-
ondary sterility it may be necessary to se-
cure better obturation by grasping the two
lips of the cervix with a bullet forceps. The
internal os. however, is intact even in these
cases and as the cannula is introduced be-
yond it the ordinary cannula insures satis-
factory obturation. A mucus plug should be
cleaned out and the cervical canal painted
w^ith tincture of iodine.

When the external os is narrow it is
necessary to use a cannula of correspond-
ingly smaller caliber or it may be advisable
first to dilate it gently to proper width.

Occasionally obstruction is encountered
near the internal os. Here of course the test
cannot be carried out. This is an incidental
finding which has particular significance in
the problem of sterility for that given pa-
tient. In such case it is first advisable to
overcome the stenosis by proper dilatation
and then later on the oxygen insufflation
may be tried. I have had two such cases in
my series.

Uterine Insufflation of Oxygen Compared
to Intranterine Injection of Solutions
Opaque to the X-Ray as a Test of Tubal
Patency. — My experience with the injection
of solutions opaque to the .r-ray included
collargol, thorium and bromide. All of these
are useful when the tubes are occluded.
(Figs. 4 and 8.) When the tubes are patent
the roentgenograms are not uniformly satis-
factory because the solution escapes into the
peritoneal cavity and not enough of it is left
to show in the tube lumen. (Fig. 5.) Col-
largol leaves deposits in the tubes which may
or may not be absorbed. Thorium and bro-
mide in solution do not leave precipitates.
Peritoneal irritation by chemical action with
consequent adhesions is a possibility to be

borne in mind. Whether or not this may be
the case, an objectionable feature to the use
of the solutions is the uterine colic, accom-
panying and following the injection. Pa-
tients do not tolerate this so well. In this one
respect the oxygen insufflation has a particu-
larly superior advantage. Any residual oxy-
gen within the uterus is immediately ex-
pelled with the removal of the cannula. The
other advantage of no less importance is
that the oxygen is readily absorbed by the
tissues and does not leave irritative preci-
pitates. Only exceptionally will one en-
counter a uterus that may be called irritable
to the oxygen. It is more apt to be in a very
nervous woman. In my experience with the
oxygen insufflation I have succeeded in com-
pleting the test in every case, although in
two instances I had to defer the test for an-
other time owing to apprehension on the
part of the patient. It is conceivable however
that in cases of endometritis and perime-
tritis of more recent date the uterus will be
tender to the manipulation.

Oxvgen does not show in the tubes when
patent. In the anatomical specimen it may
show very faintly in the skiagraph (Fig. 6)
when the tubes are ligated at the fimbriated
end but not in sufficient density to appear in
the living subject w'here the contrast is ob-
literated by neighboring shadows, etc. Occa-
sionally in a case where both tubes have been
removed and the uterine cavity is large, hav-
ing a capacity of 40 to 50 c.c, one may suc-
ceed in getting a good outline picture with
oxygen. I have had one such result. (Fig.
7.) Our experience in attempting to demon-
strate the oxygen in uteri during the injec-
tion with the exception of this one case has
so far not been satisfactory although we
have not made a persistent effort in this
direction.

Conditions in which the Intra-uterine
Oxygen Insufflation Method Has Been
Found Useful. — i. Primary and absolute
sterility of several years' duration with no
jrross lesions ascertainable. This is the ideal
group for the test.

2. Sterility of long standing where pelvic

I2J

Subphrenic Pneumoperitoneum by Insufflation of Oxygen

masses are palpable and clinically diagnos-
ticated as fibroids or "chronic diseased ad-
nexa." The test shows whether or not the
tubes are open.

3. Cases in which one tube was removed
for inflammatory disease or for unilateral
ectopic to determine the normality of the
lumen of the residual tube.

4. Cases in which there is a history of an
attack of appendicitis with peritonitis in the
premarital or postmarital state to exclude
tubal occlusion by a residual adhesive peri-
tonitis.

5. Cases following a pelvic exudate or
abscess with or w^ithout operation and where
apparent resolution has taken place and vet
sterility is complained of.

6. To test the pro1)ity of the tubes in
cases where tubal ligation was done with
the object of permanent sterilization.

7. To test the continr.ity of the genital
canal in cases where the conservative opera-
tion of myomectomy, single or multiple, was
done in the hope of relieving sterility.

8. To test the result of plastic operation
on the tubes in cases of bilateral salpin-
gostomy.

A detailed account of these results will
be taken up in a clinical consideration of the
problem of sterility.

CONCLUSION

The method of intra-uterine oxvgen in-
sufflation to produce an artificial pneumo-
peritoneum establishes the fact of patencv

or occlusion of Fallopian tubes. Under
manometric and volumetric control it is a
scientific, diagnostic procedure and may be
employed with safety to determine the me-
chanical factor involved in the etiology of
female sterilitv. For this purpose it obviates
the necessity of surgical exploration and is
s])ecific.

As the fact of tubal patency is in most
cases i)rimarily a matter for speculation, its
scope for general abdominal diagnosis as
compared to that offered by the direct ab-
dominal puncture metohd is necessarily lim-
ited. In cases where the tubes are patent,
however, a pneumoperitoneum of any size
ma}" be produced by the uterine route.

For the definite object of establishing
tubal patency by intra-uterine insufflation,
only a diminutive amount of gas is neces-
sary because the result desired is to produce
a localized subphrenic pneumoperitoneum
which shall be followed by scant if any
symptoms. The vast majority of the patients
tolerate this method very well and it may be
employed as a routine office procedure. The
use of carbon dioxide instead of oxygen will
diminish the symptoms following insuffla-
tion almost to a vanishing point. It is well
however to bear in mind the primary object
of the test and to apply it only in cases
properly suited for its use. In these it has
proved of great diagnostic and prognostic
value.

In 150 cases, with a t6tal of 170 examina-
tions, there haA'e been no imtoward sequelae.

THE DETECTION OF RETROPERITONEAL MASSES BY THE
AID OF PNEUMOPERITONEUM

By L. R. SANTE, M.D.

Instructor of Radiology, St. Louis University Medical School ; Radiologist to
St. Louis City Hospital

ST. LOUIS, MISSOURI

' I ** HE wider use of pneumoperitoneum as
"*■ an aid to radiological diagnosis of ab-
dominal conditions is fast bringing the sub-
ject from the stage of generalities to that of
more special methods of examination.

The number of experiences encountered,
even in the fifty pathological cases which we
have had. is so large that it would seem
more advisable and probably be more profit-

the lower right quadrant of the abdomen.
The case was the occasion of some dispute
among the staff, as to whether the mass was
attached to the kidney or not, and a pneumo-
peritoneum examination was made to try to
determine its origin. By the ordinary an-
tero-posterior plate, it was found that the
mass was entirely free from both kidneys,
and that it extended downward to the pelvis

Fig. I. Retroperitoxeal Position. Patient Prone. Chest and thighs supported on two Mocks, allowing
the abdominal wall to sag freely without pressure.

able to consider one of the groups into which
these cases fall rather than to undertake a
discussion of the subject in general. I shall,
therefore, confine this paper to one of the
groups of cases in which we have found this
method of great aid; I refer to the detection
of retroperitoneal masses.

Early in our experience with pneumoperi-
toneum, we encountered a case which proved
to be of great value to us in developing a
technique for the detection of retroperitoneal
masses. I shall outHne the case, as it pre-
sented itself. B. C, a well developed, colored
male, age twenty-six, presented himself, with
a slightly tender, very hard, smooth mass in

and across the midline, causing nearly as
large a mass, as yet undiscovered, on the left
side. In an effort to determine the relation
of this mass to the ureter an injection of
thorium was made into the kidney pelvis
and a [)late was made showing the smooth
gentle curve of the ureter. A second plate
was then made while exerting upward and
inward pressure on the mass with a cone,
and the radiograph showed a distinct kink-
ing of the ureter, suggesting that the mass
was retroperitoneal and that the ureter
passed anterior to it. Destruction of the
bodies of the 4th and 5th lumbar was noted,
and the possibility of the mass being a tuber-

129

I30

Retroperitoneal Masses Detected by Pneumoperitoneum

cular abscess was at once considered. In an
effort to demonstrate the origin of the mass
more clearly, the patient was examined in a
prone position (Fig-, i). chest and thighs
supported on two l^locks taking all pressure

leaving a clear space between them and the
retroperitoneal structures. The liver is at-
tached by the triangular ligament to the dia-
phragm, and drops forward also, to a greater
or lesser extent in different individuals ac-

FiG. 2. Psoas Abscess Shown in the Retruperitoneal Position- Encroaching
UPON the Praevertebr.vl Clear Space.

off' the abdomen and allowing the anterior
abdominal wall to sag freely between the two
supports. The retroperitoneal character of
the mass and its complete separation from
the kidne}S was then clearly shown (Fig. 2),
and since the mass originated in the area of
destruction of the lumbar spine, the diagno-
sis of psoas abscess was made, which was
confirmed by subsequent developments.

Since this prone position demonstrated the
retroperitoneal origin of the tumor mass so
clearly in this case, it was not long before
we made a closer examination of its possi-
bilities in other cases. A moment's consid-
eration of the anatomical arrangement in
this position may serve better to illustrate
the cases which are to follow. (Fig. 3.) It
will be noted that if the patient is suspended
on two blocks, so as to take all pressure off'
the abdomen, the belly wall will sag down
and all of the intra-abdominal organs with
mesenteric attachments will fall forward

Fig. 3. The Patient, PkEviorsLV Overiustenpep, is
Supporter upon Two Blocks, allowing the anterior
abdominal wall to sag down freeh-. The intestines
and all organs with mesenteric attachment have
fallen forward, leaving a praevertebral clear space.
Any retroperitoneal mass will encroach upon this
clear space.

cording to the location of this attachment,
forming a triangular .shadow with the apex
at the diaphragmatic attachment. If the indi-
vidual is normal this space should be clear; if

Retroperitoneal Masses Detected by Pneunioperitoiievim

i^i

a retroperitoneal mass is present, this space
is encroached ni)on. Fi,e;-ure 4 shows in a
gross way the ajjpearance of a normal indi-
vidual in the retroperitoneal position. Note
that the intestines and all structures with
mesenteric attachment have fallen forward
and that the prevertel)ral space is clear and

J. M., white, male, age thirty-two, pre-
sents on examination a large tumor mass on
the left upper abdomen; not painful and
moving only slightly, if at all, with respira-
tion. On inflation the mass was seen to have
no connection with the anterior abdominal
wall, although it did protrude well forward

Fig. 4. Radiogr.xph of a N'ormal Ixiuvihu.vl ix the Retropeuitoxe.m. Position. Intestines and organs
with mesenteric attachment have fallen forward, leaving clear praevertebral area. Encroachment
upon this space !)y a mass originating in the retroperitoneal tissues can be clearly seen.

Fig. 5. New Growth of Left Kiuxev Seex ix the Ivetroi'Eritoxe.\l Positiox to Excro.xch upon the

Pr,\evertebr,\l Cle.\r Sp.vce.

not encroached upon. The liver shadow is and was represented by a shadow in the

seen with its diaphragmatic attachments. middle of the al^domen. An antero-posterior

To illustrate the value of this position let examination revealed the extent of the mass

us proceed to the second case. to be even greater than supposed and it

132

Retroperitoneal Masses Detected by Pneumoperitoneum

seemed to go down into the pelvis. The liver
was shown to be uninvolved.

An examination in the lateral position
showed the spleen clearly separated from tlie
mass but the left kidney could not be defin-
itely outlined. In an effort to determine
whether the left kidnev was involved in the

sition with Figure 5 as a result. The intes-
tines, stomach and all organs with mesenteric
attachment have fallen forward. The liver
has dropped exceptionally far forward and
the only organ which still remains in place is
the spleen, which i)robably is adherent some-
what to the diaphragm, and which may also

Fig. 6. (.-Ihovr) Pkrixei iiumc Arscess Sho\vi\(. I)ii-ii se rather E.\tensive Encroachment of

THE Mass upon the Praevertebral Space.
Fig. 7. (Beloz^<) Large Sarcoma of Kidney Shown in the Retroperitoneal Position to Encroach
UPON THE Praevertebral Clear Space to a very Considerable Degree.

mass, the ureters were catheterized and 20
c.c. of thorium nitrate injected with the re-
sult that nothing more than a misshai^ed
shadow appeared within the tumor mass.

To rule out a possible origin from the
large bowel, a barium enema was given. The
colon was perfectly normal and encircled the
tumor without in any way being attached to
or compressed by the mass. Lastly, as a final
step in the pneumoperitoneal examination,
the patient was put in the retroperitoneal po-

have Ijeen prevented from displacement by
the shelf-like projection of the mass. The
mass itself can be seen taking origin among
the retroperitoneal tissues and extending
forward to encroach upon the prevertebral
space. Diagnosis of a new growth involving
left kidney was made.

iV third instance illustrating the advantage
of this position will be seen in the case of
M. S., white, female, age thirty-three, who
presented on examination a palpable mass in

Retroperitoneal Masses Detected by Pneumoperitoneum

133

the right lower abdomen which was very ten-
der both on abdominal palpation and over
the back, and was thought to be a movable
kidney. Pneumoperitoneum examination re-
vealed a diffuse, hazy mass on the right side
below the liver and widely separated from it.
Examination in the retroperitoneal position

inal tumor occupying the entire left side of
his abdomen, innumerable small nodules un-
der the skin all over the body. The abdom-
inal mass seemed to move slightly with res-
piration and on first examination was
thought to be the spleen. Antero-posterior
view made by the aid of pneumoperitoneum

Fig. 8. Retroperitoneal Carcinoma Secondary to Carcinoma 01 thk Ki mhik >i i \ 1~xcroaching
UPON THE Praevertehral Space. Note the slightly rotated position necessary when dealing with
retroperitoneal masses in the pelvis.

was made (Fig. 6) and a rather extensive
obscurity of the retroperitoneal tissues was
seen. The liver and all organs with mesen-
teric attachment have fallen forward, but
the spleen is adherent and seen in its posi-
tion in contact with the diaphragm. The
mass encroaches upon the prevertebral space
but seems to be more diffuse. Psoas abscess
was considered but no carious vertebrae
could be found. Tumor of the kidney was
thought of, but a plate showing clearly the
kidney outlines was obtained and the radi-
ological diagnosis was a probable peri-
nephritic abscess. Operation confirmed this
diagnosis.

The fourth case in the study of this
method of examination, was likewise very
interesting. J. V., colored, male, age nine-
teen, presented besides an enormous abdom-

at once showed the extent of the mass and
showed its separation from the spleen. The
lateral view also showed the mass to be very
extensive, with areas of irregular density
and an oval, more or less smooth outlined
mass at the top. A small stringy-like shadow
resembling the kidney pelvis was seen in the
midst of the mass and on looking up the rec-
ords of the case it was found that ten months
previously there had been an injection of his
kidney pelvis made with thorium nitrate. In
this plate his kidney outline showed also very
well, but since his complaint was the same it
is quite probable that this was at the incep-
tion of his disease. The diagnosis was not
made at that time. Finally examination was
made in the retroperitoneal position (Fig. 7)
and a large retroperitoneal mass was found
projecting forward into the prevertebral

134

Discussion of Pneiinioperit<^neiim

space and almost obliterating it. Diagnosis of
tumor of the left kidney was made. Opera-
tion and pathological section established the
diagnosis of sarcoma of the kidney.

When the pathological process is low-
down, so that the shadow of the mass falls
below the shadow of the innominate bones,
the patient, still in the retroperitoneal posi-
tion, must be rotated slightly towards the
side of the tumor, in order to get a view un-
obstructed by the crest of the ilium.

The following case presents c[uite clearl\-
the use of the retroperitoneal method of ex-
amination in tumors low down or in the pel-
vis. F. L., white, male, age sixty, presented
upon examination a large rounded tumor
mass, arising just over the symphysis, and
extending to the umbilicus. With frequent
\()iding of small amounts of urine and tene.-^-
mus, the patient looked very similar to one
suffering from urinarv retention from an
hypertrophied prostate. Pneumoperitoneum
examination was made and a large mass
about the size of a child's head was seen
almost completely to fill the pelvis. A dark
shadow just above the symphysis was taken
to be th'C collapsed bladder, and on injection
this proved to be the case ; the mass was
separated from the bladder. A barium enema
was given and the sigmoid was seen to run
over the mass but was unobstructed in its

course, and give the impression of a retro-
peritoneal mass, which had in its growth
merely pushed the large bowel forward.

The patient was examined, slightly ro-
tated in the retroperitoneal position (Fig. 8)
and a large retroperitoneal mass was found,
widely separated from the bladder. No bone
destruction of spine or pelvis was found.
Cystoscopic examination of the bladder was
made and a carcinoma of the bladder was
found. Diagnosis of retroperitoneal carcin-
oma, secondary to a carcinoma of the blad-
der was made.

To outline briefly the essentials for a satis-
factory retroperitoneal examination:

1. It is especially essential when this ex-
amination is to be undertaken, to clean out
the bowels well, using vegetable cathartics.

2. The patient should void his urine just
before examination.

3- He should be given little if any food
just pri<^r to the examination.

4. He should be orcr-tiistcndcd with the
inflating medium.

5. He should be sufficiently well supported
to exert no i)ressure on the interabdominal
contents.

We have to date used this position in the
detection of retroperitoneal masses witb
continued satisfaction and feel that it will
ultimately be of great value for this purpose.

DISCUSSION FOLLOWING SYMPOSIUM ON ARTIFICIAL
PNEUMOPERITONEUM

In addition to Dr. Rubins' and Dr. Sante's articles in this issue of the Journal, the Symposium
includes the following: Pneumoperitoneurn of the Pelvis: Gynecological Studies, by James
G. V'an Zwaknvenberg, M.D., January issue, p. 12. Piieuinopcritoiiciini as an Aid in Differ-
ential Diagnosis of Diseases of the Left Half of the Abdomen, by A. F. Tyler, M.D.,
February issue, p. 65. The use of CO^ in Producing Pneumoperitoneum, by Walter C.
Alvarez. M.D., b^ebruary issue, p. 71.]

Dr. Leopold Jaches. The roentgenologic
method in connection with Dr. Rubin's work
was developed b}' my associate, Dr. Bendick,
and I have seen a relatively small proportion
of these cases, but I can assure every roent-
genologist here that it is a very easy procedure,
that it doesn't take much time. There is no fuss

about it. We have \ery frequently been able
to do one or two or three cases between other
fluoroscopies. There is absoluteb' no fuss at
all.

I am not as pessimistic as Dr. Rubin is with
regard to the possibility of determining which
tube is patent and which is closed. It should

Discussion of Pneumoperitoneum

135

not be very difficult to do so fluoroscopically
during the time of the inflation.

We have not yet at the hospital a fluoro-
scope appropriate for this work, but as soon as
our Dessane bonnet arrives we shall investi-
gate this phase of pneumoperitfjneum.

Dr. J. \V. HuNTiCR. I should like to inquire
of Dr. \^an Zwaluwenberg if ])regnancy can
be diagnosed by the pneumoperitoneum method
unless the head or some of the bones of the
fetus are shown on the plates. The reason I
ask that is because I did not notice an}- on the
slide which he showed us.

Dr. James G. Van Zwalu\\exberg. With
regard to the demonstration of pregnancy
without the actual demonstration of bony parts
of the fetus, I am very optimistic that we shall
be able to do this because there must be differ-
ences in de\'elopment and enlargement of the
uterus from those of pathological enlarge-
ments. We haven't seen a great many of these
cases, and I don't know positively whether
that is so, but so far we have have had no
myomata of the uterus which looked anything
at all like pregnancy, and we have plates of
one case whose last menstruation was six
weeks before the examination, one which Dr.
Peterson insisted was pregnane}', and the
changes in the uterus are altogether charac-
teristic. That is his opinion. I tliink there will
be very little difficulty in dift'erentiating the
distortion of the uterus by a myoma or other
enlargement from that of a pregnancy.

To Dr. Stewart, we owe a great obligation,
because the idea of the work was directly sug-
gested by some of the plates he showed at
Saratoga. The objection he has met, w^e also
are meeting. The Department of Gynecology
has been the subject of considerable ridicule
for using this method, on the ground that they
should be able to make all their diagnoses
without it. As a matter of fact, the gynecolo-
gist usually knows prett}' well what he is
going to find when he opens the pelvis, but
the fact remains that sometimes he doesn't,
as Dr. Rubin's case, in which there were
double pus tubes which were not suspected,
illustrates. The same sort of thing has hap-
pened in our experience. I doubt if the method
will ever become routine. We are doing it
routinely now until we have established a basis
for our opinions, which, at this time, aren't

worth a great deal, but I have great hopes
that some system of standarfls can be estab-
lished which will make this method of real use.

Dr. L. R. Sante. I noticed that iJr. Rubin
referred to the pneumoperitoneum showing
more on one side than on the other in these
cases, and I would like to offer the following
as a possible explanation: The mesentery of
the small intestine, as we know, is attached
on the posterior wall of the abdomen in an
oblique position. I wonder if this does not act
as a wall, thereby confining the oxygen more
on one side of the abdomen or the other de-
pending upon which tube is patent.

Dr. Rubin (closing). I am glad to have
heard the explanations of the api)earance of
the unilateral pneumoperitoneum. I am quite
free to say I did not think of all those things.
Tt may \-er}- well be, though, because in the
beginning we had the patient get off the table
on one side or the other, and it is very likely
that that occurred, but lately we have had the
patient sit bolt upright, so that the explana-
tions given could not be true in that event, and
so some other explanation may be necessary.
Dr. Sante's suggestion of the slanting mesen-
ter}- ma}' be true in some cases. On the other
hand, as Dr. Stewart explained, the gas takes
the path of least resistance and is influenced
by the weight of the viscera. It may very well
be that sometimes the stomach is heavier than
the liver. As a rule, the liver is heavier than
the stomach.

About the contra-indications : I would like
to repeat them again. The presence of pus in
the genital canal, urethra, vagina or cervix, and
the presence of fever due to pelvic inflamma-
tion are contra-indications. Even though there
is an inflammator}' process, however, if there
is no fever, that lesion is quiescent, and the
introduction of 150 c.c. at 200 pressure will
not do an}' harm. It will not do any harm when
the fallo])ian tubes are closed, at least in my
experience I have seen no harm result in such
cases.

Another thing I want to consider is the
theoretical possibility of the formation of em-
bolism. I tested this problem out by actually
introducing oxygen into the vein of a dog, and
found that 350 c.c. of oxygen injected into the
vein did not as it were cause the dog to "turn
a hair." Now, if 350 c.c. of oxygen, which is

136

Discussion of Pneumoperitoneum

the very maximum dose which I require for
my patients, does not affect a dog by direct
intravenous application, it certainly will not do
any harm in the human.

I think someone asked about sterilizing the
parts. The apparatus I use consists of specu-
lum, tube, single tenaculum hook, and a can-
nula. These are, of course, boiled. The vagina
is wiped clean of whatever mucus may be
present, and the cervix touched with iodin.

Dr. L. R. Sante. The wider use of pneu-
moperitoneum in abdominal conditions has
brought the subject from the stage of gener-
alities to that of more special methods of ex-
amination. This you have seen to-day in the
examination of the pelvic organs, by Dr. Van
Zwaluwenberg, in the special examination of
the spleen, and also, as mentioned by Dr
Tyler, in the detection of abdominal masses.
I am glad to hear, also, that Dr. Stewart
spoke of the difficulty in dift'erentiating kidney
masses, and to see that he showed a case
which he infers is a retroperitoneal mass.

When we first started this work about a
year ago in the City Hospital in St. Louis, v e
were greatlx' handicapped to get a routine
technique which would be at once rapid and
sufficiently thorough to secure all of the nec-
essary points in the examination. The number
of positions in which it was necessary to place
the patient was the greatest difficulty we had
to overcome. We finally brought into use a
type of hospital cart, balanced upon two
wheels, so that mere pressure upon the cart
at either end would raise or lower the head or
feet. This we found most efficient.

When we first undertook this work we fol-
lowed very closely the technique of the first
writers upon the subject, using oxygen as an
inflating medium and employing manometers to
ascertain the intra-abdominal pressure. Later
we used air as an injecting medium and now
we use a very simple apparatus. We have dis-
pensed with all manometers and measuring ap-
paratus and use merely a lumbar puncture
needle, connected by suitable tubing and con-
nectors to the pump of a Potain aspirator with
a Murphy drip interposed as a trap, the small
vent hole of which has been plugged. The
entire apparatus except the pump is sterilized.
The air is not sterilized in any way. We have
found that air takes considerably longer to
absorb, six to seven days, than oxygen, three
to four, but it surely causes less pain; and

since we practice deflation on nearly all of our
patients after examination, we count the use
of air a distinct advantage. We have no diffi-
culty in determining when the needle is in the
abdominal cavity by simply listening with a
stethoscope on the opposite side of the abdo-
men for the characteristic sound of the pump.

The routine procedure which we have
adopted is to wheel the patient before a verti-
cal fluoroscope while lying on his back.

The needle is inserted, and the patient in-
flated under the fluoroscope. When sufficient
inflation is obtained, the needle is withdrawn.
He is then rolled over into the lateral position
and examined on each side. After this he is
put in the so-called retroperitoneal position,
which I will describe later, to determine if any
retroperitoneal masses are present. He is then
examined in both the dorsal and ventral po-
sitions on the horizontal fluoroscope.

One case, which proved to be a retroperi-
toneal mass, illustrated so well the position I
am about to show you for the detection of
these masses, that we very soon conceived the
idea of using it in many other cases.

The patient presented himself with a mass
in the right lower quadrant, very hard and
well defined, and of questionable origin. It
caused quite a controversy among the sur-
geons and the genito-urinary man, as a result
of which we made pneumoperitoneum exami-
nation and fortunately for us, it showed the
outline of the mass very clearly, and that it
was in no way connected with the kidney. In
an effort to determine whether the mass was
retroperitoneal, we injected the ureter and
kidney pelvis. We noted the smooth outline of
the ureter, and then by pressure on the mass
with a cone, directing the pressure upward,
and inward, were able to demonstrate a kink
in the ureter. This seemed to indicate that the
ureter ran over the mass, and that the mass
therefore was retroperitoneal. We noted, also,
the carious appearance of the third and fourth
lumbar vertebrae, and suspected a tuberculous
abscess. He was then put in this position —
chest and thighs supported by two blocks —
with his abdomen hanging loosely between ; ex-
posing from side to side, we obtained a view
of the retroperitoneal and prevertebral space.
The mass was retroperitoneal, and proved to
be a psoas abscess. You will note that the pre-
vertebral space, which is usually clear, is en-
croached upon in this way. This case demon-
strated so well the advantage of this position

Discussion of Pneumoperitoneum

137

in demonstrating retroperitoneal involvement
that we began to utilize it for this purpose in
other cases.

This is a diagram merely to show the ar-
rangement of the abdominal organs in this
position; the abdominal wall sagging between
two blocks permits the intestines and all or-
gans with mesenteric attachment to fall for-
ward, showing clearly the retroperitoneal
structures and clear prevertebral space. If
there is a retroperitoneal mass, this mass en-
croaches upon this clear prevertebral space.

The first case is a mass which was not at-
tached to the anterior abdominal wall. In this
case, we rolled the patient on the side and
showed that the spleen was high up under the
diaphragm and entirely independent of the
mass. To determine whether the mass was con-
nected with the kidney, we injected the ureter
wth thorium, and found an irregular mass in
the midst of this area. The colon was injected
to see if it was the origin of the mass, but it
did not seem to have any connection with it.
Examination in the retroperitoneal position,
however, disclosed very clearly that the mass
was retroperitoneal, and was closely associated
with the left kidney. We have used this posi-
tion successfully in determining the presence
and origin of a sarcoma of the kidney ; a
retroperitoneal carcinoma secondary to car-
cinoma of the prostate, and closely associated
with the kidney ; a perinephritic abscess ; a
psoas abscess ; an abscess arising in the sem-
inal vesicle and a retroperitoneal carcinoma
secondary to a carcinoma of the bladder.

I feel that with more extensive use this
position will prove of great diagnostic value
in determining the retroperitoneal character of
masses.

Dr. Carlos Heuser, Buenos Ayres. With
the dental anaesthetic apparatus of Clark, in-
tended for oxygen gas and ether, I use a
mixture in the proportion of 35% gas to
15% sulphuric ether by drops which are
mixed with the gas and 55% oxygen, giving
1500 to 3000 c.c. of this mixture with my
special needle. The advantages are as follows :

1. The patient can be examined standing.
Deep breathing does not hurt him..

2. The mixture is absorbed rapidly.

3. The patient is not left with any pains.

4. The method can be used in the consult-
ing room.

5. There have been observed no abnormal
symptoms.

6. With the manometer attached to the in-
strument, it is possible to measure the quan-
tity of gas injected, to know the pressure, and
whether or not the gas mixture has penetrated
into the abdominal cavity.

The needle is of platinum with a special
mandrin and an escape key similar to the or-
dinary trocars. The purpose of the mandrin is
to prevent the needle from bending when the
puncture is made. The cannula with the es-
cape key gives escape to the air after the
roentgenogram has been finished. I leave the
cannula in the abdomen during the making of
the plates. I consider this method a great ad-
vantage and a great relief for the patient.

Dr. W. C. Alvarez. Generally we put in
gas with the patient on his back. It seems to
me that this gas might be trapped on one side
or the other, depending on whether he rolls
over to the right or to the left. Much depends,
also, on whether the body is quite even on the
table.

T think this type of case which Dr. Sante
has just described is the type in which you
must use oxygen or air or something else that
will stay. It is well not to use too much ; one
to two litres I find is generally sufficient. Don't
do this work for idle curiosity, and don't do it
if there are any signs of inflammation.

Dr. a. F. Tyler. I would like to ask Dr.
Alvarez if he has had any trouble in introduc-
ing carbon dioxide with the patient going into
shock.

Dr. Alvarez. I have had nothing like that.^
Most of the patients have had very little
trouble. Don't let them sit up or stand up until
they have had the gas in them for some time.

Dr. William H. Stewart. Dr. Rubin's
work on testing the patency of the fallopian
tubes by means of injecting oxygen into the
uterine cavity is entirely foreign to pneumo-
peritoneal .r-ray diagnosis, so much so that the
speaker does not feel competent to discuss the
communication although he can readily ap-
preciate the value of such a procedure.

INote: Since this meeting I have seen one case with
most alarming cyanosis and stoppage of the heart,
showing again that this technique should not be used
thoughtlessly or needlessly.

138

Treatment of Malignant Patients Undergoing Radiotherapy

Dr. Van Zwaluwenberg's presentation has
been most enhghtening, particularly so as the
practical value of pneumoperitoneum in pelvic
cases has long been a question in the speaker's
mind. Many gynecologists will not accept the
method as a routine procedure, saying that
they are able, except in some very obscure
cases, to make their diagnosis without pneu-
moperitoneum. There is every indication, how-
ever, that the method will be so simplified that
it can be used in all cases where a diagnosis
cannot be made by the ordinary mediods.

Dr. Sante's remarks with reference to the
question of gas collecting on one side of the
peritoneal cavity, is debatable. Personally the
speaker believes it is purely a coincidence, for
unless the abdominal cavity is inflated to a
considerable extent the gas is apt to collect
in any one place. One of the difhculties to
contend with in this work is to obtain a uni-
form distribution of the gas. Intestines which
are distended with gas or feces will prevent
this uniform distribution, and frequently form

pockets in the peritoneal cavities where the
inflated gas will accumulate.

Dr. Alvarez' communication is most im-
portant and great credit should be given to
him for the suggestion of the use of carbon
dioxide instead of oxygen. The inflation tech-
nique which we are emplo}'ing at the present
time is somewhat similar to that reported last
year. If a complete fluoroscopic as well as
roentgenological examination is required, oxy-
gen is the gas of selection. Should the investi-
gations be of a single organ, such as the gall-
bladder, carbon dioxide is used. This gas is
absorbed very rapidly, usually disappearing
in about half an hour. A mixture of 2 parts
of carbon dioxide to i of oxygen is very satis-
factory where the investigations will consume
about an hour.

[The speaker showed lantern slides of a
series of cases in which pneumoperitoneum
had proved of great value in securing a
diagnosis.]

THE COLLATERAL TREATMENT OF MALIGNANT
PATIENTS UNDERGOING RADIOTHERAPY*

By E. H. skinner, M.D.

KANSAS CITY, MISSOURI

T) ROBLEMS are constantly arising in the
-^ management of malignant patients who
are undergoing radiotherapy. The comfort
of our patients and their symptomatic care
is quite another thing from the actual appli-
cation of radiant energy.

There are two aspects to radiotherapy and
the malignant patient. The one presupposes
that the application of the radiant energy is
the one essential. The patient and his disease
are overlooked in an ambition to secure the
proper dosage and consequent shrinkage of
the tumor mass.

The viewpoint that I wish to present may
be summed up in the aphorism: Beyond the
cancer is the cancer patient.

If we had a panacea for malignancy in ra-
diant energy there might be some excuse for
overlooking the patient and simply treating

the malignancy. Unfortunately this is not so.
Therefore we shall probably achieve a more
reasonable success if we observe ways and
means to promote the comfort and symp-
tomatic relief of our patients. The more one
is engaged in the handling of this class of
patients, the more does one realize that our
therapy is far from being a specific in spite
of the remarkable changes that the tissues
obtain from radiant energy.

The chief difficulties with our malignant
cases are poor morale, deficient appetite,
irradiation sickness, distressing local symp-
toms and the subtle changes in the blood
and internal secretions. Upon the latter,
much may be conjectured, little is known;
but it may not be amiss to venture certain
observations, relate certain animal experi-
ments and their possible application in ra-

*Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn., Sept. 14—17, 1920.

Treatment of Malignant Patients Undergoing Radiotherapy

139

diologic practice. The former group of sys-
temic difficulties is met in almost every case
of desperate malignancy. The local symptoms
necessarily vary with the type of involve-
ment.

The subject easily divides itself into the
following headings :

1. The mental attitude of the patient.

2. The general state of health of the pa-
tient.

3. The dietetic care of the patient.

4. The adjuvant therapy of local and gen-
eral symptoms.

5. Amelioration of symptoms by variation
of dosage.

The Mental Attitude of the Patient. — Pa-
tients come to the radiologist with great
hopes of relief and possible cure. Every ef-
fort should be expended to maintain this at-
titude even to the extremity of prevarication,
because it is noticeable that the patient loses
rapidly as soon as he loses hope. This hope-
ful attitude is an enormous factor. The phy-
sician should, however, never fool himself or
the family. There should be a perfect under-
standing between the radiologist and some
responsible member of the family.

On the other hand if the patient comes to
the radiologist reluctantly and without hope
it behooves one to make every effort to raise
the morale of the patient by encouraging the
fighting spirit and hopeful attitude. This is
hardly fair in the absolutely hopeless case.
The judgment and experience of the radiolo-
gist is far more important than the potency
of his irradiation in this situation. Again
would I invoke the words of Shakespeare:

... to thine own self be true,
And it must follow, as night the day,
Thou canst not then be false to any man.
Hamlet, Act I, Sc. 3.

This buoyancy of hope is a greater factor
than tonics in maintaining the general condi-
tion and the appetite of the patient. The
cheerful attention of the physician and those
in contact with the patient and the minimiz-
ing of the symptoms to the patient are
worthy ideas.

The General State of Health of the Pa-

tient.— The general state of health of the pa-
tient which necessarily includes the diet
should be constantly in mind, for in our ef-
forts to eradicate malignant tissue we may
be taking advantage of the reparative powers
of the patient or developing gastric symp-
toms which will negative our local results.
Every radiologist must be cognizant of the
violent gastric symptoms which are coinci-
dent with radiant therapy, especially of the
abdomen. There are reliable reports of
metastases supposedly caused by vigorous
treatment of the apparently localized malig-
nancy. There is ample evidence from animal
experimentation that radiation has the ca-
pacity of destroying the very cell factors in
the blood which are at the same time the
most potent agency in the actual destruction
of the malignant cell. We refer to the lym-
phocytes of the blood. While heavy dosage
will destroy the lymphocytes, small repeated
doses will stimulate their development. The
thought therefore arises — is it always best
to attempt to overwhelm a malignancy with
deep penetrating dosage, or should an at-
tempt be made to fortify the patient by
stimulating his cellular resistance to malig-
nancy ? Furthermore, may we not be hasten-
ing or actually producing metastasis by vig-
orous primary radiation? The idea of im-
munizing the patient by gradually increasing
dosage may be worth consideration.

In spite of the dissensions of opinion re-
garding the so-called acidity or alkalinity of
cancer patients, it is our humble experience
that it is more comfortable to the patient to
promote the alkalinity of the excretions and
at the same time quiet the gastric symptoms.
The milk of magnesia is a most valuable
remedy, as It tempers the stormy stomach
and favors colonic regularity. The drinking
of waters which carry a high soda content is
more agreeable than frequent dosage with
soda bicarbonate. The latter Is valuable to
promote a rapid alkalinity when the patient
is first seen and for acute attacks of gastric
discomfort, but the milk of magnesia and the
waters are better for long periods of time.

The Dietetic Care of the Patient. — When
one seeks the literature for Information upon

I40

Treatment of Malignant Patients Undergoing Radiotherapy

the dietetics of malignancy one finds con-
tradictory ideas. For many years the teach-
ings of Bulkley have held us to the idea that
alkalinity should be the goal. The experience
of radiologists with deep irradiation sickness
and the general relief of symptoms by soda
bicarbonate seems to make us disciples of
Bulkley. Now comes one worthy Joslin to the
opposite opinion with an interesting array of
argument :

"There never was in the world two opin-
ions alike, no more than two hairs or two
grains; the universal quality is diversity."
Montaigne.

"Inconsistencies of opinion, arising from
changes of circumstances are often justifi-
able." Daniel Webster, Vol. v, p. 187.

"Thus times do shift — each thing his turn does

hold;
New things succeed, as former things grow

old." — Herrick.

Experience and custom seem to demand
that the general diet should tend toward
alkalinity. Milk and the vegetables and
cooked fruits and cereals are easily the basis
of the daily dietary. Bulkley has outlined
very specifically the intimate details of rotat-
ing variations in the daily meals. Torbett
has furnished an alliteration that sticks:
"Prunes, plums, peanuts; Canteloupe, cab-
bage, cranberries; these are foods which
leave acid radicals in the blood." It is well to
remember that spinach is richer in iron than
any other vegetable and that the baked po-
tato eaten with the skin furnishes a great
deal of lime. Whole-wheat bread and pop-
corn are happy thoughts.

Dietetic experiments upon rat tumors,
quoting Corson-White, reveal that a diet of
vegetable protein, fat, and carbohydrates re-
tard the growth of tumors, while the general
condition of the animal seemed normal. On
the contrary, high cholestral feedings seem
to increase tumor growth. Hunt Reid finds
that it may be well to consider diets that in-
fluence the ductless glands; oats and potas-

sium iodide stimulate the thyroid, while eggs
and milk inhibit the thyroid.

As an element which may be of increasing
interest we would suggest blood transfusion
for the patient who has a decided alteration
in the blood picture due possibly to irradia-
tion. This procedure may be considered
where there is a low lymphocyte count or a
pernicious anemia. In the former it would
probably be wiser to withdraw a certain
amount of blood and then donate a similar
amount from a properly typed doner. In the
latter case — pernicious anemia — a properly
typed blood could be given without any with-
drawal. It is probably best to hypothecate
that the low lymphocyte count is due to ir-
radiation and there is no decrease in the red
blood cells, while in the pernicious anemia
the condition is a sequela of the malignancy.

The Adjuvant Therapy of Local and Gen-
eral Symptoms. — Therapeutic suggestions
may be grouped as general or local.

General measures are Blaud's pills, bitter
tonics, potassium iodide, arsenic and strych-
nia, arsenical injections (salvarsen). proto-
nuclein and glandular extracts. There is no
reason why the patient should be denied the
possible advantages of remedial measures of
historical value simply because they are now
undergoing a treatment by radiation and
hope.

The use of arsenical injections and gland-
ular extracts to enhance the value of radia-
tion is worth consideration. We would also
reiterate the values of the milk of magnesia
and alkaline waters as general therapeutic
measures in every case.

The local symptoms vary. With uterine
malignancies we have the bladder and rectal
symptoms (eminent radiologists to the con-
trary). With sigmoid and visceral malig-
nancy there are few local symptoms. With
mouth and throat cases, there are the dis-
tressing symptoms of ptyalism, pain, and ul-
ceration and bleeding.

Brief local measures are suggested as fol-
loivs: — Pelvic malignancy. Peroxide cleans-
ing. Mild astringent tampons. Chloretone
and icthyol tamponage. Acetone packing.

Treatment of Malignant Patients Undergoing Radiotherapy

141

Dakinize with extreme care for the viable
tissues for twenty- four hours at three days'
interval.

Breast Malignancy: Potassium perman-
ganate for ulcerations. Salt pork poultices.
Screening with parafine mesh. Balsam peru.
Peroxide cleansing. Aristol dressing.

Mouth Malignancy: Potassium iodide to
promote mucous membrane activity and
atropine in alcoholic to physiologic equili-
brium for ptyalism. Potassium chlorate for
mouth wash. Pack ulcerations with soda bi-
carbonate. Silver nitrate applications.

Pain: Start with aspirin. Add phenace-
tine. Turn to papine. Then codeine. Terminal
refuge is morphine.

The cancer patient is entitled to relief
from pain, as there is nothing to be gained by
fighting the pain or bearing the pain. It is
bad enough to endure an incurable malig-

nancy, so why add the burden of pain and
discomfort. Irradiation surely reduces and
sornetimes eliminates the pain .and it surely
affords an easy exitus for the desperate
malignancies even if it does no more.

There is no dolibt but that irradiation by
.r-ray and radium is the greatest boon that
the malignant patient has had during all the
ages, and it has surely come to stay as a pos-
sible cure in many conditions ; at least a pro-
longation of life is assured, and always com-
fort to the patient when not a cure.

BIBLIOGRAPHY

I BuLKLEY. Therap. Gaz., whole series, xl. 3 s., 1916,
xxxii, I. N. York M. J., July 3, 1915.

2. Gaylord. Surg., Gynec. & Obst., 1917, xxiv, 95.

3. Corson-White. Penn. M. J., 1919, xxii, 348.

4. Murphy. /. Am. M. Assn., 1914, Ixii, 1459. /. Ex-

per. M., xxii, 204, and xxii, 482.

5. ToRBETT. Personal Communication.

THE AMERICAN JOURNAL OF ROENTGENOLOGY

H. M. Imboden, M. D., Editor - Paul B. Hoeber, Publisher

Issued Monthly. Subscription, $6.00 per year. Advertising rates submitted on application. Editorial ojfice,
480 Far\ Avenue. Jiew "Yor^ Office of publication, 67-69 East -^gth Street, Jiew lCor\.

Information of interest to all readers and lists of ojfcers of The American Roentgen Ray Society and
The American Radium Society will be found on the two pages preceding Table of Contents.

TWENTY-SECOND ANNUAL MEETING THE AMERICAN ROENTGEN RAY SOCIETY

WASHINGTON, D.C., SEPTEMBER 27, 28, 29, 30, I92I

Headquarters, Meetings and Ey<i}iibits: Hotel V/ashington. Hotels: Hotel 'Washington and The Jslew Ebbitt.
SIXTH ANNUAL MEETING THE AMERICAN RADIUM SOCIETY

BOSTON, JUNE 6 AND 7, 192I. HEADQUARTERS, HOTEL BRUNSWICK

WASHINGTON MEETING

PRELIMINARY ANNOUNCEMENTS

Plans for the program of the Annual
Meeting of the Society next fall are now well
under way. Dr. Rene Ledoux-Lebard will
give the Caldwell Lecture on the subject of
"Deep Roentgen Therapy." It is planned to
give a much larger place on the program to
papers than has hitherto been done. The plan
is to hold the meeting for four days, giving
the entire first day to papers on therapy and
to have the papers on physics during the
forenoon of the second day. This will enable
those who are interested only in therapy to
leave about the middle of the second day,
while those interested only in roentgen diag-
nosis would not feel it necessary to attend
until the beginning of the second day. Those
interested in both diagnosis and therapy
would probably wish to be present the entire
four days.

It is believed that this plan will make the
meeting of interest to a much larger number
of men. It is requested that those who have
papers to present at the meeting communi-
cate with the President of the Society at as
early a date as possible.

A. C. Christie.

The Twenty-second Annual Meeting of
The American Roentgen Ray Society
will be held in Washington, September 27,

28, 29 and 30, 1 92 1. Headquarters, meetings
and exhibits will be at the Hotel Washington,
Pennsylvania Avenue, opposite the Treasury.

Hotel accommodations for members and
guests may be arranged at the Washington
Hotel and The New Ebbitt. In making res-
ervations state that you are attending the
meeting of The American Roentgen Ray
Society. Mr. A. Gumpert, Manager of the
New Ebbitt, has agreed to see that all those
attending the Convention are taken care of.
Therefore anybody not getting what he
wants should communicate direct with him.

The hotel rates are as follows:

Hotel Washington, every room having
private bath with shower, tub and running
ice water (European plan only) :

Single rooms

Double rooms (double bed)

Double rooms (twin beds)

Per day
$5.00 to $7.00
8.00
10.00 to 12.00

The New Ebbitt (European plan only) :

Per day
Single room without bath $2.50

Sing-le room with bath

4.00

Double room without bath, each person $2.50
Double room with bath, each person, 3.50

Also a niunber of large suites, both with
and without bath, which will comfortably
accommodate upwards of four persons. On

142

Editorials

143

these suites they would make a rate of $3.00
per day each person, with bath, or $2.00 per
day each person without bath.

For information regarding the program,
those wishing to read papers or to show
slides at the meeting should communicate
direct with the President, Dr. A. C. Christie,
1 62 1 Connecticut Avenue, N. W., Washing-
ton, D. C.

For information regarding commercial ex-
hibits and other business matters connected
with the meeting, address the Business Man-
ager, Paul B. Hoeber, 67-69 East 59th
Street, New York City.

It is hoped to arrange for special trains
and cars from various sections. Details re-
garding this will be announced later.

THE CALDWELL LECTURE FOR 1921
The American Roentgen Ray Society
is very fortunate in having secured Dr. Rene
Ledoux-Lebard of Paris to give the Caldwell
Lecture at the annual meeting this year. The
distinguished standing of Dr. Ledoux-Le-
bard as a roentgenologist and his charming
personality make it certain that the high
standard already established for this lecture
will be maintained.

Annual Meeting Western Section

The Pacific Coast Roentgen Ray Society
will meet at the same time and place, the two
organizations being the guests of the Portland
Roentgen Club, a very active organization of
specialists.

The Secretary of the Western Section would
welcome a visitor or two from the East with
papers or demonstrations, and can assure them
of a very enjoyable meeting. Address Dr. War-
ner Watkins, Box 1328, Phoenix, Arizona.

REPORT OF MIDWINTER MEETING
CENTRAL SECTION

The Second Annual Midwinter Meeting
of the Central Section of The American
Roentgen Ray Society was held in St.
Louis, at the Hotel Statler, on February 21
and 22, with about eighty-five in attendance.
The program for the two days is as follows:

Monday Morning, February 21, ig2i

9:30 Opening with a Business Meeting.

Appointment of Nominating Commit-
tee.

Dr. J. M. Martin, Dallas, Tex. X-ray
Treatment of Acne Vulgaris.

Dr. D. Y. Keith, Louisville, Ky.
Sarcoma Therapy.

Dr. Charles C. Grai^dy, Fort
Wayne, Ind. Fracture of the
Pelvis.

Dr. L. T. LeWald, New York City.
Report of a Case of Hernia of the
Diaphragm on the Right Side
(Confirmed by operation).

Dr. D. C. Upson, Battle Creek, Mich.
Situs Inversus.

Dr. H. J. Ullmann, Chicago, 111. The
Use of the Sphere Gap for
Measuring Voltage in Roentgeno-
therapy.
I :oo Lunch.
2:00 Election.

By Invitation:

Dr. George Dock, Professor Internal
Medicine, Washington University
Medical School. X -Ray from the
Viewpoint of an Internist.

Dr. J. M. Cork. The X-Ray Spectrum
and its Relations.

Mr. Frank Rieber, San Francisco,
Cal. The Importance of Accurate
Standardization of Tube Poten-
tial in Therapy.

Dr. Cliarles Hugh Neilson, Profes-
sor Internal Medicine, St. Louis
Medical School. The Internist's
Vieivpoint of the Roentgenolo-
gist.

144

Editorials

Dr. p. M. Hickey, Detroit, Mich.
Roentgen Diagnosis of the Pan-
creatic Cysts.

Dr. a. W. Crane, Kalamazoo, Mich.
Reconsideration of the Barium
Meal.

Dr. E. H. Skinner, Kansas City, Mo.
Congenital Atresia of the Esopha-
gus.

Executive Session for the Election of
Officers.

Monday Evening, February 21, ip2i

7:00 Banquet.

Lantern Slide Exhibit.

Tuesday Morning, February 22, ip2i

9:30 Clinical Visit to Washington Uni-
versity ]\ledical School and Barnes

Hospital.
Tentative program had been arranged
as follows:

(a) Dr. E. L. Opie, Professor of
Pathology, Washington Univer-
sity Medical School. Tuberculosis
(Demonstrations of specimens,
lantern slides, etc.).

(b) Dr. R. Walter Mills, Dr.
Sherwood Moore. Demonstra-
tions in the X-Ray Department.

12:00 Central Dry Plate Company Visit.

Buffet Luncheon (Courtesy Central
Dry Plate Company).

Practical Demonstration of the Var-
ious Stages in Dry Plate Alanu-
facture.

Visits to Local Laboratories.

The morning and afternoon sessions of the
first day were occupied with reading and dis-
cussing the very interesting and scientific
papers by the members and invited guests.
These papers ranged in subjects over the
viewpoints of the physicist, internist, diag-
nostician, and therapist.

Dr. Dock and Dr. Neilson, Professors of
Internal Medicine in the Washington L^ni-
versity Medical School and in the St. Louis
University INIedical School, respectively,
brought out an important point which could

be taken as a criticism in part of the roent-
genologist and in part of the consultant: viz.,
that while there are many cases in which
diagnoses can be given on one examination,
there are still a large number that should
have repeated examinations before the posi-
tive findings are rendered. They cited as in-
stances, cases sent long distances because of
chest findings, and major operations under-
taken because of abdominal findings.

The banquet was well attended, and the
pleasing music provided by the St. Louis
Committee was enjoyed by all. The toast-
master, Dr. Skinner, won the hearts and ap-
plause of all when he announced that owing
to the lateness of the hour and the previous
entertainment, speeches would be dispensed
with.

The lantern slide exhibit, following the
banquet, lived up to its usual reputation, and
was the most fascinating part of the meeting.
Dr. R. Walter Mills presented a series of
interesting stomach slides with tables show-
ing his classification of the different types of
the human form, each type having its char-
acteristic stomach picture. Many other mem-
bers exhibited a variety of slides, and much
good-natured rivalry was brought out in try-
ing to show some condition or anomaly not
previously seen by one of our visitors.

The midnight sessions were held as usual
in the various rooms.

On the morning of the second day the
members were driven to the wonderful
University Medical School and Barnes Hos-
pital, where Dr. Opie, Professor of Path-
ology, lectured on tuberculosis, using lantern
slides for demonstration.

A splendid buffet luncheon was served to
the Society at the Central Dry Plate Com-
pany, after which the plant was inspected
and the methods of plate-making were seen.
It was necessary to traverse the dimly lighted
parts of the factory in chain-gang fashion, as
the ordinary dark-room is lighter and more
easily negotiated.

A vote of thanks was given to the St.
Louis Committee for their splendid arrange-
ments and entertainment.

Dr. J- G. Van Zwaluwenberg presided.

Editorials

145

Dr. A. F. Tyler, the Secretary, was unable
to be present; Dr. William M. Doughty was
appointed Temporary Secretary.

The Local Committee consisted of Dr.
Edwin C. Ernst, Chairman, and Drs. E. H.
Kessler, Fred B. Hall, M. B. Titterington,
and L. R. Sante.

The following officers were elected for the
next year :

President

Dr. William M. Doughty, Cincinnati, Ohio

First Vice-President

Dr. D. Y. Keith, Louisville, Kentucky

Second Vice-President

Dr. E. S. Blaine, Chicago, Illinois

Secre tary- Treasurer
Dr. A. F. Tyler, Omaha, Nebraska

The next meeting will be held in Chicago,
the date to be decided later.

ADDENDUM

Dr. Alfred S. Doyle makes the following
addition to his article on page 73 of the
February issue:

In the American Atlas of Stereoroentgen-
ology, Vol. II, Dr. H. M. Imboden of New
York reports a case injured in October,
1 91 6, which was operated upon October
nth, for depressed fracture. Roentgen ex-
amination made November 8th shows an
area of diminished density in the upper por-
tion of the cranium which he believed at that
time was air in the cranial cavity. On De-
cember 7th of the same year another roent-
gen examination was made and shows the air
completely displaced by brain tissue ; this
patient is reported as having made a com-
plete recovery without operation for the air.

DOSAGE MEASUREMENT

A Criticism

By J. S. SHEARER

CORNELL UNIVERSITY, ITHACA, N. Y.

Some years ago the writer of this article
published a paper on the photographic effect
of .r-ravs when variations of current and

voltage were made and no filtering material
except the walls of the tube and the usual
paper envelopes were between the target and
the sensitive emulsion. The results showed
that for a given wave form the time required
to secure identical blackening of spots on the
same plate could be quite accurately com-
puted by assuming that:

1 . The time was inversely proportional to
the current when voltage and distance were
unchanged.

2. The time was inversely proportional to
the square of the effective voltage when cur-
rent and distance remained fixed.

3. The time was directly proportional to
the square of the target plate distance for
current and voltage unchanged.

Thus for unfiltered rays the photographic
effect was indicated by the relation
current X (voltage)^ X time
(Target — plate distance)^
Also the reasonably accurate reproduction of
results with different machines, as indicated
by photographic action when reasonable care
was taken, suggested the use of these meas-
urements in the place of Kienbock strips or
pastilles. This was advocated because obser-
vation of the work of many students showed
there was better agreement in results than
when the prevailing methods were employed.
Measurements by ionization methods have
indicated the above formulation to be sub-
stantially correct within the range of volt-
ages in common use and where wave forms
do not vary too much. Also, since in this
same range "spark gaps" are nearly propor-
tional to voltages, gap measurements may be
substituted for voltage. The use of this
method has become fairly general in this
country, and we now see statements of cur-
rent, gap, filter, distance and time as a rule
instead of so many H or X units.

The general principles of physical meas-
urements are sometimes rather complex and
are often not well understood. This is always
true when methods are developed and units
adopted before facts can be fully investi-
gated, also methods are frequently applied
in ranges outside their proper limitations.

146

Editorials

As an example, assume that we wish to
use a photographic method to measure light.
Let portions of a plate receive exposures for
I, 2, 3, 4, etc., units of time to radiation from
a constant source. No one would question
that here exposures would be in proportion
to the times. If we lay off along a horizontal
axis a series of equal steps as o-i, 1-2, 2-3,
etc. (Fig. i), we may erect perpendiculars

Fig. I. Vertical Lines Show Densities Corre-
sponding TO Exposures Shown at Base. Thus A4
is 1.9 in length, B5 is 3 units, or 4 arbitrary- ex-
posure units gave 1.9 units of density.

at these points whose lengths correspond to
the measured density of the negative where
these exposures acted. Suppose one made
measurements between A and D, and ob-
served that here density increased very nearly
in proportion to exposure. A unit for expo-
sures might be chosen as U, and we say that
A received 4 units, B, 5 units, C, 6 units. Any
other area having a density equal to that at
A would also be said to have received 4 ra-
diation units. If now we attempt to use the
density of the negative as a measure of ex-
posure below A, or above D, we have trouble,
since a small exposure may cause no meas-
urable density. Neither can we infer from the
density K what exposure the corresponding
spot received. For had the relation between
exposure and the density produced not
changed, then this particular density would
have been attained by a shorter exposure.
Thus no determination of exposures below
or above certain limits are possible: below

there is little or no density, while above the
density changes but slightly even with great
increase in exposure.

The same applies to a pastille, too little
exposure will not cause a perceptible color
change, and after a certain yellow brown tint
is reached no further change in tint is ob-
served. Also if an exposure exceeding certain
limits is made there is no way of determining
hozv much excess radiation has been received.
Pastilles were introduced when induction
coils and gas tubes were in general use and
there were wide differences in outfits. The
fact that their maximum change in tint was
so nearly attained by exposure to a quantity
of radiation that could safely be delivered to
the skin made them exceedingly valuable for
skin therapy at that time. But in the use of
fractional doses, heavy filtered doses, and
when we consider the difficulties of keeping
and reading pastilles we recognize the need
of some other measure.

We sometimes say that one quantity "runs
parallel" with another, meaning they increase
or decrease together in a fixed ratio. Thus on
the straight line portion of Figure i, expo-
sure and density "run parallel" over a con-
siderable range, but not over all ranges. The
biological action of many, perhaps of all
stimuli, varies with the dose according to a
law similar to that "of decreasing returns"
in economics, or by an approximately logar-
ithmic or exponential law. Thus Figure 2

Fig. 2. A Common Relation Observed between
Cause and Effect. The second unit of cause gave
\y2 effect units. The 7th only .3 of a unit.

Editorials

147

shows such a curve. To assert that each unit
of the acting agent produces the same ejfifect
would be absurd, as successively applied
units of causation give entirely different ad-
ditions to the effect. And yet that is just what
is so often done in the use of "pastilles,"
Kienbock's, etc., in therapy.

The therapist need not be concerned with
such units at all. What he needs to know is
hozv to operate his tube to secure the most
favorable curative result with the least risk ;
viz., what current, voltage distance, filter,
time, areas of entry, and intervals between
treatments are most likely to secure a good
therapeutic effect with a minimum risk of
skin lesion. Also under what conditions may
this dose be exceeded and by how much,
when the net result may be favorable to the
patient, even though temporary injury to the
skin ensues.

Such a specification of dosage may seem
not to involve any consideration of the laws
of physics. But this is not the case and es-
pecially so when one considers questions of
deep therapy, of filters, of proposed varia-
tions in apparatus and countless other phases
of the development of therapy in which we
are bound to be guided by our concepts of
physics. The well established laws of radia-
tion need no defence, neither do their careful
consideration in the matters at hand require
any apology.

It seems to the writer quite unfortunate
at this time, when we are shortly to be able
to clear up many of the disputed points in
therapy, to have several articles in this and
other journals giving c(uite erroneous inter-
pretations of observations. The first article
by Remer and Witherbee in June, 191 7,
questioned the voltage law as measured by
pastilles. There was no reason to assume that
photographic densities and color changes
would run parallel to each other or either of
them to skin effects over any considerable
range. And no claim had been made that such
was the case.

In this same article the inverse square law
was c{uestioned when filters were used. While
the writer dislikes to appear controversial,

references to his work have been made in
several of these articles, and he has recently
received letters from many sources asking
if the published results are in accord with
his experiments. This seems to make a public
answer unavoidable, especially as the writers
of some of these letters say they had unfor-
tunate results when believing they followed
Witherbee and Remer's formulation.

As in many other cases many of the ob-
servations of these authors are of value
even though their explanations may be
wrong, but explanations based on incorrect
ideas almost invariably lead, sooner or later,
to absurd or dangerous procedures. In some
cases they result in the development of im-
proper or useless appliances, in others in se-
rious injury to patients, and they always
tend to bring the work into disrepute.

When writers challenge the validity of
well established physical laws they must ex-
pect a critical scrutiny of their contentions.
So in the present case we may consider va-
rious statements of these authors as to their
concordance and probability. In all of With-
erbee and Remer's work full reliance is
placed on their pastille readings or on color
changes on the skin. As regards the latter
one might secure a fairly pronounced ery-
thema that would hardly be deepened in color
by a considerable increase of exposure.
There may also be quite a difference in bio-
logical effects at greater depths for the same
apparent erythema. As regards the compari-
son of erythemas and coloration of the skin
it would be well to remember that precon-
ceived notions may unconsciously greatly in-
fluence readings in color matching. It is cer-
tainly questionable whether an ordinary
photograph of the patient's skin is a reliable
indication of the effect of radiation.

Taking now the article by these authors in
the N. Y. Medical Journal, June 26, 1920.
We may note reference to the work of 191 7,
where it was first asserted that the inverse
square law was in error for filtered rays. All
factors except distance remaining the same
it is stated that at half distance one gets only
twice instead of four times the dose. Or if

148

Editorials

one gets, say, 4 units at 10 inches one would
get 2 at 20 inches instead of only i.

Such a result is contradictory to all physi-
cal experience with radiant sources as small
as we have in the jr-ray tube where the vari-
ation of distance from various points of the
source to an external point is too slight to
consider. The claim is also self-contradictory
since any given filter absorbs a definite frac-
tion of the radiation it receives quite inde-
pendent of the intensity. Placed close to the
source more is received and more absorbed,
further away less is received and correspond-
ingly less is absorbed, but always the same
fraction of that received.

Now the authors admit the inverse square
law is all right for unfiltered rays.

Suppose a filter, F, (Fig. 3), is placed at
5 inches from T and the radiation is received
on an areas S just beyond F. Let F receive 8

L..i:-__

..£....

Fin. 3. F just in front of S receives 8 units of radia-
iLon, it filters out Yi or transmits 4 units. This gives
only one unit on an area S ' equal to S but twice as
far avi^ay. Remer and Witherbee say it gives 2
units. Transfer F to F', they admit that if not fil-
tered the intensity at F' (no filter at F) would be
only 2 units and it removes 50% and we get only
I unit on S'.

arbitrary units of radiation per sq. cm. and
be of such a thickness as to absorb 50 per
cent of this amount, then a sq. cm. perpen-
dicular to the rays just beyond F would re-
ceive 4 units. According to Witherbee and
Remer a sq. cm. of surface S, at 10 inches
would receive two units instead of only one
as predicted by the inverse square law. Now
move the filter twice as far away to F; at
10 inches it is admitted that the filter would
receive only one fourth of what it did at 5
inches, or only 2 units.

Receiving only 2 units and absorbing 50
per cent of what it received, it would trans-
mit only one unit. So it would follow if the

physical law is not obeyed it would make a
great difference where we placed the filter,
while in fact it makes no difference.

It is interesting to observe that their claim
as to the effect of distance is exactly com-
parable to their observation on change of
voltage, i.e., if the V^ law is true we would
have four times as riiuch rediation for a
doubled voltage. They say only twice as
much. Halving the distance gives four times
as much radiation on the same area, but these
authors say they read only twice as much.
Does it not seem strange they should get this
exact discrepancy in two different cases and,
granting as good readings as possible, would
not one be justified in doubting the method ?
Next in this article we read that dosage is
not in proportion to time. Using 3 mm. of al.
and all remaining conditions the same:

2 min. gives i H

2y^ 2 min. gives i ^ H

3X2 min. gives 2 H
Summarizing, if at a voltage V, distance D,
and time T, we get a dose H :

Physical laws Witherbee &

predict: Remer assert:

/2D

4H 2H

3H 2H

' —

TT7-

-1

■

¥■

' —

■—

' — ~^

—

' — ;

——

^T~

' ' :

'■'/

lil: t\

::^U

J/^

■~~

rrrr rr

■tt

'A\\\

'^ rrf ^

II til II

■U-U- Ij

-U

_„

-— -

—

ill

5.^

—

\'^

'-'f

."-

r, /

■

— t

]

,,,, 1 .

-X

—

4t-

-TT-

~T~

h- ,--.:.

_-^__

.— ,

—

L-

U-

L-

lilt
T

tirlff

jfM

^Wi^

Fig. 4. Increase in Dose Indication with Equal
Increments of Time. Dotted straight line shows
how an indicator ought to behave. Full line shows
Remer and Witherbee readings. . Exterpolated be-
yond by dotted lines. Uncertain just how it would
read at 4T.

Editorials

T49

This failure of the pastilles to read in pro-
portion to time according to the observations
reported is significant. In Figure 4 the
straight line shows the increase of dose with
increase of time, all other factors unchanged.

T = time for i skin unit. But their read-
ing at 2T must be increased by one third of
itself to come to 2H, the reading at 3T must
be increased by 50 per cent of itself to give
3H, and extending the curve, in the absence
of readings, to 4T, indicates that the reading
at 4T would have to be increased about 80
per cent to satisfy the law of constant in-
crease with time. Hence if under one set of
circumstances the pastille is so much too low
that one must add 80 per cent to 2H to get
a rational measure, just why not add, say,
100 per cent to the 2H reading in the voltage
and in the distance experiments?

The law of uniform increase of dose zvitJi
time for all other conditions constant has
always been used to determine the fractional
scales for both the Kienbock and pastille
methods. After a reading of 2H was attained
we were told to double the time for 4H.
Thus the scales used by these authors were
fixed by using the laws whose validity they
deny.

There should be a careful distinction be-
tween applied dose and the effect produced
by the application. Thus if 5H is the dose
received by a pastille it shows a marked
change in color, if an additionad dose of 5H
is then applied bu*- little further color change
is shown. The dose is a physical entity, its
effect is dependent on the variable state of
the receiving substance. Also if a tendency to
recover is present we have another factor in-
volved. Thus with very weak radiation in
moist air and diffuse light one may have the
rate of recovery of a pastille just balance the
action of the radiation, yet one would hardly
claim no dose.

In this same article we read as follows:

"Recently the pastille readings were taken
using %, Yz, I, 2, 3, 4, 5, 6, and 7 mm. of
aluminum, respectively. Throughout these
experiments, instead of the half distance pas-
tille registering tzuice the amount of that at

full distance we find that when the half dis-
tance pastille reaches one and a half skin
units the full distance pastille reads one skin
unit and when the half distance pastille
reaches two skin units the full distance reads
one and a quarter. The only exception to this
is when 5, 6 and 7 mm. of aluminum are
used. These register half the dose of full dis-
tance and formula. This agrees with the bio-
logical results."

It is rather strange that only after 5 mm.
are used do we get agreement with biological
results.

In their previous work they declared a
ratio of I to 2 for 3 mm. of aluminum at full
and half distance. The physical law asserts
the ratio is always i to 4.

Remer and Witherbee read i to 1.5 at first,
then 154 to 2, or I to 1.6 up to 4 mm. of
aluminum, then at once i to 2. So we see that
the pastilles are not consistent with them-
selves as the ratio of readings is variable
when two are treated alike for comparison.

—

■ -'

—

-y

r" ;

—

'/t -

c ■

ti.

-tfi

1^^'

''-t

-if.—

-_i

Ll^

iiii

30]

It;

4: :■

—

— -

—

~~-

—

— -

—

/(7\

—-

—

*i:

—

t: ■

!jlj

Hl-ll

iSi

■till

Fig. 5. Exposure Times for iH, Current, Distance
AND Gap Constant but Using Different Thick-
nesses OF Aluminum. Such an irregular line is
highly improbable.

One way in which we may see whether re-
sults are fairly reasonable or not is to plot
curves between two related quantities. Plot-
ting from the data given, time for one skin

ISO

Editorials

unit at constant gap, current and distance
against thickness of aluminum used as a filter
we have Figure 5. Such results are quite im-
possible unless all experiments done hereto-
fore are wrong. Why such a break at 3 mm.
and such a jump between 4 and 5? And
surely no one knowing anything of the effect
of thickness can believe that 7 mm. and
upwards would transmit the same amount of
radiation as 5 mm.

Again we read:

"The principle involved in this experiment
apparently changes the classical law of light,
namely, the amount of light varies from the
source according to the inverse square of the
distance. Filtered .^-ray produces double the
amount of half distance instead of four
times.

"We understand that these results in no
way conform to any existing law of physics.
We have been unable thus far to explain the
cause of the above phenomena and simply
wish to report our findings."

The authors further remark: "W^e do not
see the necessity of using more than five
mm. of aluminum as a maximum without the
addition of a piece of glass, leather, or
wool." Why add glass, leather or wool?
Because of some property not recognizable
by physical experiment? Or because some
have used these as filters? At the end of
the reprint we are told their "results explain
the practicability of filtered ray for pro-
ducing the maximum effect on the parts be-
neath the skin when compared with unfiltered
dosage." A fact fully explained without any
need of the denial of the laws of radiation.
The whole result of these arguments is, if
anything, to discredit entirely such methods
of measurement.

In the Medical Record, July 31, 1920, we
have another article entitled "The Cause of
Z-Ray Burns."

There appears in this article so much that
is fallacious that it constitutes a serious men-
ace to rational therapy. Omitting the figures
that purport to show equality of dosage by
ordinary photography of the skin the main
portions of the article may be quoted. The

paragraphs are numbered solely for easy
reference.

1. "During the early days of roentgenology,
when the gas .ar-ray tube was all there was, we
were especially warned against the use of any
factors with very low voltages, for the reason
that low voltages produce an immense number
of rays of low penetration which are absorbed
by the skin and hence more liable to cause an
;tr-ray burn than the high voltages whose rays
are of high penetration and not absorbed b}'
the skin.

2. "The above theory has been handed down
from year to year and it is only within the last
few years that the fallacy of it has been
realized.

3. "Soon after the announcement of Sabor-
aud and Noire method of treatment of ring-
worm of the scalp, many attempted to carry
out the procedure with an .sr-ray coil instead
of a static machine as used by the originators.
This resulted in overdosage and permanent
baldness in many of the cases. The reason for
this was the failure of the operator of the coil
to maintain a constant high voltage for any
length of time as compared with the tube main-
tained by the static machine.

4. "This drop in voltage in the gas tube no
doubt increases the number of low penetrating
rays, and it was naturally concluded from the
theory of absorption that they were the cause
of permanent alopecia or jtr-ray burn. In order
to test out this theory, the following experi-
ment was made with a Coolidge Tube and re-
ported in the June issue o.f 1917 of the Ameri-
can Journal of Roentgenology.

5. "Four areas of a patient's back were
treated with the following factors for each
area:

MA Sp. G. T

No. I. 3X3X5 = ly' skin units = kK;
8DX8D

No. 2. 3X6X2j^ ^ j^ skin units = 5H;
8X8

No. 3. 3X45^X3^ ^ J i^ gi^ij^ yj^i^g ^ fj
8X8 . 0 '

No. 4. 3X9X1^ ^ ji^ gj^jj^ yj^j^g ^ -fj_
8X8

6. "The photograph of the patient taken

Editorials

151

ten days after treatment demonstrates that
all areas coincide, yet in two of them, namely
No. 2 and No. 4, the spark gap was doubled
and one-half the time taken for exposure that
was given in No. i and No. 3, respectively. It
therefore follows that if the spark gap is
doubled and the time reduced one-half, the
same degree of erythema will be produced,
other factors remaining constant.

7. "From the standpoint of quaUty of .r-ray
in the above experiment, the formula with 6-in.
and 9-in. spark gaps (No. 2 and No. 4) should
give a very large percentage of penetrating
rays as compared with the 3-in. and 4^/2 -in.
(No. I and No. 3), and hence one would ex-
pect that these penetrating rays derived from
the higher spark gaps, 6 and 9 (No. 2 and 4)
would pass through the skin and take much
longer to produce the same degree of erythema
as that followed by the use of 3 and 4^ -in.
formulae (No. i and No. 3). Exactly the re-
verse proves true. For it took just one-half the
time for the same biological effect in the
doubled spark gaps (No. 2 and No. 4) as it did
in the 3 and 4^-in. (No. i and No. 3)
formulae.

8. "It is, therefore, apparent that the quality
of the ray and the absorption of those of long
wave length have little to do with the biological
effects in the skin. On the other hand, it seems
that the factor which determines this effect is
solely the quantity of .:r-ray reaching the skin,
for it is obvious that a high spark gap produces
more rays that reach the skin than the same
dose with a low spark gap.

9. "Recently we have tried out the following
factors on the skin of a patient's back :

MA Sp. G. T

5X9X9/1-6 min. __

6X6 D
33^ sec. = 1/4 skin unit

^H.

10. "This is an er}thema dose without a
filter. The filtered erythema dose using 3 mm.
of aluminum is as follows :

MA Sp. G. T
5X9X77 mi"- _
6 D
25^ skin units = loH.

thema are identical. No. i was produced by
the unfiltered erythema dose ; No. 2 by the
filtered erythema dose. Biologically, to all ap-
pearances, the erythema produced in 33^ sec-
onds by the unfiltered ray is the same as that
produced in 7 minutes and 42 seconds by the
filtered.

12. "If the voltage determines the quality of
the ray, then in this experiment the voltage is
the same in both instances ; the only differ-
ence is the interposition of 3 mm. of aluminum
and about ten times longer exposure for the fil-
tered dose as the unfiltered. Here again the
quantity of x-xz.y reaching the skin is materi-
ally lessened by the aluminum, thus making the
enormous difference in the time of exposure.

13. "This dose with 3 mm. of aluminum
takes a little over ten times as long to produce
an erythema as it does without aluminum. In
speaking of this dose some writers would say
that they gave ten erythema doses. This state-
ment without qualification is misleading. In
reality the effects, so far as the skin reaction
is concerned, are identical. If then the filtered
and unfiltered erythemas are the same, the only
difference being in the number of rays reaching
the skin, thus increasing the time, why is it
that a filtered dose is five or ten or any other
number of erythema doses? The fact remains
tliat biologically filtered and unfiltered erythe-
mas are identical, as exemplified in Experi-
ment No. 2, illustrated in Fig. 2; that 1%. skin
units unfiltered = 5.H or one erythema dose,
also that 2^ skin units filtered or one filtered
erythema' dose.

14. "By increasing the thickness of the filter
and decreasing the spark gap the time neces-
sary for a filtered erythema dose, namely 2^/2
skin units can be progressively increased.
Although decreasing the spark gap in unfiltered
dosage lengthens the time of exposure for an
erythema dose, the time ratio between the
lower voltages and the thickness of the filter is
many times greater than those of the higher
voltages. Therefore, one might select a formula
with a very low voltage and be able to say that
one gave forty or fifty erythema doses.

15. "If then, in describing the technique of
filtered dosage we adopt 2^ skin units as the
standard for an erythema dose, we can use it
with the same degree of accuracy as we have
the erythema dose of unfiltered dosage."

II. In the photograph both areas of ery- Among the lessons learned by the early

152

Editorials

roentgenologists at the price of bitter expe-
rience the one that stands without modifica-
tion to-day is stated in paragraph i. The
"fallacy" is solely in the proposed explana-
tion by these authors.

When the voltage at which a tube is oper-
ated is reduced, rays of all kinds (i.e., of all
wave lengths) emitted by the tube are de-
creased in intensity, none whatever are in-
creased, many are reduced to nothing. The
static machine gives a larger percentage of
sJwrt wave lengths than a coil operated at the
same spark gap. It may also be remarked that
if one operates a coil with inverse through
the tube the milliampere reading will be the
difference between direct and inverse so that
one might even have the meter read zero and
yet operate the tube. In such a case we surely
would have excess dosage. But now the
authors introduce experiment and then inter-
pretation as in paragraph 7. There is here
exhibited a common confusion of mind in the
use of the term quality of x-ray. If a tube
operated at a 4}^ in. gap, emitted only one
(ray?) i. e., one wave length, h, and at a 9
in. gap it ceased the emission of h, and sub-
stituted,a new, more penetrating ray of wave
length I2, and if these carried the same en-
ergy the "much longer" contention claimed
as a prediction from the theory would be well
founded. But the facts are entirely otherwise,
and the so-called "reverse" only shows a mis-
conception of well founded laws. There are
rays at a 9 in. gap more penetrating than any
at a 43^2 inch, also all those present at a 4^2
inch gap are present in increased intensity at
a p inch gap.

On account of the smaller percentage ab-
sorption of the rays of higher penetration
that are added when the operating voltage is
raised one should not expect that the time
for erythema would be reduced to one-fourth
by doubling the gap but the writer believes
that it is reduced much more than stated in
the article quoted.

Paragraph 8 is the most dangerous mis-
statement relating to .r-ray therapy that the
writer has read in a long time. To say that
the absorption of waves of long length has

little to do with biological effects is to con-
tradict all experience. Again experiment and
explanation. Two doses, equal according to
the belief of the authors were given to a
back and a photograph taken. Suppose they
had given 8 min. or 9 min. with filter and
25 sec. or 40 sec. instead of 33^ without
filter, would the photographs have been dif-
ferent? In other words how accurately does
equality of negative density or even the
unaided eye as a measure of erythema in-
dicate dosage? And if accurate enough for
skin therapy are they good guides for deep
therapy ? Also the writer sincerely hopes no
one will use a p in. gap and a 6 in. target
skin distance.

In 12 we again see lack of perception of
the real facts. It is true that the quality of
the beam before filtration was the same in
the two cases, also the filter did reduce the
quantity of all wave lengths reaching the
skin, but the reduction is enormously greater
in the long wave lengths so the quality of
the radiation reaching the skin in the two
cases ivas very different. The only remark
which we might agree with is the objection
to describing dose by the number of X or H
units or multiples of erythema doses.

Now it is true that the same skin effect
may result from the absorbtion of equal
quantities of radiation irrespective of the ac-
tual wave lengths, but the effect is never con-
fined to the skin alone. Thus, glands are of-
ten affected to a greater Extent than is indi-
cated by the skin reaction. The patient, not
simply the patient's skin, is treated.

The article in this Journal (October,
1920, pp. 485-492) contains the same errors
as those already cited, in fact in the main it
is a rearranged reprint of the others ; note the
second column of page 488 and the difficult
expression as to gaps on page 489.

Whether or not doses of filtered radiation
such as described by these authors are both
useful and safe must be left to the experience
of those who use them. But to base dosage
on a method that is so much at variance with
well established physical laws, and giving
readings inconsistent among themselves, re-

Editorials

15:

quiring such a vast amount of useless arith-
metic can only lead to confusion.

Why cumber our literature with all sorts
of units such as H, skin units, Yz H, Hamp-
son units, X units, etc. No one conversant
with any of these units can fail to realize
the difficulties in their use. While trans-
formers and high tension rectifiers are not
perfectly comparable one with another, yet
if the rectifier is properly set and the milli-
ammeter is reasonably correct, dosage can be
quite accurately reproduced.

If experience shows that a patient having
a given disease is most benefited on the aver-
age by using a certain current, sp. gap, dis-
tance, exposed area, filter and time, that
specifies hozu to attain the desirable dose. If
the first four are constant the gap being se-
lected properly and reasonable current and
distance used, let us assume that half this
dose is given when the time is halved. Then
when quarter or other fractional doses are
prescribed there is only one factor to divide
and we have no cumbersome formulae giving
a fictitious appearance of accuracy.

Finally it will probably be found that dis-
crepancies between physical laws and
amounts and quality of radiation as esti-
mated by color changes, etc., are due either
to incorrect exposition or understanding of
physics or to defects or limitations in the

methods of measurement. In fact the writer
ventures to predict that rational radiation
therapy will finally be based on the physical
laws of radiation. The application of such
radiation will ultimately be perfected by ref-
erence to the cumulative experience of those
who apply these laws properly.

Only when dosage measurements are ex-
pressed in a common language, using terms
capable of exact meaning can we hope to
have the present chaotic condition clarified so
as to realize at once the ultimate value and
the equally important limitations of this
therapeutic agent.

Again I wish to call attention to the reason
for this criticism. I am questioning neither
the therapy nor the care or skill in reading
pastilles of the authors. Whether one should
use filtered or unfiltered radiation, 6 or 12
inch spark gap, one minute or one hour, is
not for me to say and I surely would not
discuss such matters in print. But what
therapists will do with radiation depends
very much on their conception of the physi-
cal side. The extension to higher or lower
voltages and choice of filters ought to be
based on correct use of the physics involved,
to the end that therapists may secure repro-
duction of results, or, failing that, may be
sure that the differences are due to the pa-
tient and not to the radiation utilized.

Subscribers to The American Journal of Roentgenology visiting J^ew Tor\ City, are iw
vitcd to make the ojfice of The Journal (69 East 59th Street, l^ew TorlO their headquarters. Mail,
packages or baggage may be addressed in our care. Hotel reservations will gladly be made for those
advising us in advance; in this case, \indly notify us in detail as to requirements and prices. List of
operations in Tslew Tor\ hospitals on file in our office daily.

TRANSLATIONS & ABSTRACTS

KiXGERY, Lyle B., Ann Arbor, Mich, Satura-
tion in Roentgen Therapy — Its Estimation
and ]\Iaintenance. (Archives of Dermatology
and Syhilology, April, 1920.)

Two widely separated methods of admin-
istrating radiation with ;i--rays have been in use
since the discover}' of roentgen rays ; the older
method by which the maximum effects are
graduall)'' obtained by the administration of
small doses, repeated at short intervals, and
continued over a long period of time ("frac-
tional dosage"), and differing radically, the
more recent method of "massive dosage," by
which the maximum eft'ect is obtained at once.
It is to be seen, as the writer points out, that
in each method the maximum effect is either
preceded or followed by a stage during which
the tissue effects are not definitely shown. In
the older method this occurs during the period
before cumulative eft'ects result in erythema. In
the method of massive doses, a period of in-
definite influence follows the original maxi-
mum effect.

Each cell which has absorbed roentgen rays
undergoes a biochemical change, which may
produce on appreciable effect, or may result in
stimulatibn, inhibition or erythema, according
to the quantity of radiation absorbed. Presum-
ably this sequence of stimulation, inhibition
and destruction always occurs ; it may precede
the erythema resulting from repeated small
exposures, or it may follow in the reverse or-
der, the erythema consequent to a single large
exposure. In other words, the eft'ect produced
will var}' according to the amount of rays ab-
sorbed by the cell, and one aspect of our prob-
lem becomes the maintenance of the optimum
quantity in the cell.

This depends upon the rate at which the
effects of the rays are lost. Depending on this
rate is the frequency with which exposures
may be repeated, and the quantity that* may be
administered at each exposure. The author as-
sumes that tissues exposed to jr-rays lose that
effect in a constant manner. The greater the
concentration of the biochemical products of
irradiation, the higher the velocity of loss is
borne out by certain observations. If this be
true, and if we may assume that the rate of
loss varies directly as the concentration of
some hypothetical decomposition product, then

as this concentration decreases, the velocity of
loss will become less in the same ratio. Thus,
at such time as this concentration has de-
creased by one half, the corresponding time
rate of loss shall have become less by a cor-
responding amount, and so on, until the resid-
ual effect has become negligible. This rate of
loss, theoretically, would represent a logarith-
mic curve and may be so calculated. Such a
curve has been established for many chemical
and biologic reactions, which we know as
"mass reactions," and if we may be permitted
to draw an analogy, the biochemical change
resulting from the absorption of roentgen rays
by tissue elements may follow a similar law.

Proceeding upon the basis of the above hy-
pothesis, that the decreasing residual effects
of roentgen rays follow a logarithmic curve, a
series of experiments were undertaken by
Kingery. He found that a full dose could be
repeated after an interval of fourteen days
without producing unfavorable complications.
Trying, then, the interval at which 75 per cent
and 50 per cent could be given, he found it to
be seven and three and a half days respectively,
that is, at the end of seven days, 75 per cent of
the original dose could be given without tm-
favorable reaction, and at the end of three and
a half days, 50 per cent of the original dose
could be given. From these inten'als, a curve
was constructed showing the intervals at which
a co-ndition of "saturation" diminished until
there is little effect remaining in the tissues.
By consulting this chart or curve, it is possible
at the end of four, five, six, days, or at the end
of any interval less than two weeks, to deter-
mine the percentage of the original dose given
to bring the tissues irradiated back to the same
point of saturation previously administered.

In conclusion Kinger}^ enumerates the ad-
vantages of this method :

1. Accuracy with which desired irradiation
effects may be obtained and continued.

2. Avoidance of stages of incomplete satura-
tion, perhaps of questionable influence, by
properly measured doses at proper inten^als.

3. Ability to duplicate accurately eff'ects
after various time intervals, even by different
operators.

4. Constant protection of patients from the
results of improper time and dose relations.

K. F. Kesmodel, M.D.

154

THE AMERICAN JOURNAL
OF ROENTGENOLOGY

Editor, H. M. Imhoden, M.D., 7S[eu; Tor\

VOL. VIII (new series)

APRIL, 1 92 I

No. 4

THE INTRALARYNGEAL APPLICATION OF RADIRM
FOR CHRONIC PAPILLOMATA*

By PRESTON M. HICKEY, M.D., F.A.C.P., F.A.C.S.

DETROIT, MICHIGAN

usually recommended for this condition was
employed. The growths, however, speedily
recurred. In fact, incomplete operation
seemed to stimulate the neoplasm.

Accordingly, it was decided to do a laryn-
gotomy, as the obstruction was becoming so
pronounced. An incision was made and the
larynx split, the growths were completely
removed by the curette, and the seat of op-
eration was thoroughly cauterized, after
which the larynx was closed. Microscopical
examination of the pieces removed showed
that the growth was a benign papilloma. Re-
currence, however, took place in a few weeks,
with the return of so much obstruction that
an emergency tracheotomy had to be per-
formed. After the tube was inserted and the
breathing relieved, the patient received a
thorough course of .r-ray treatments, but no
beneficial effect was noted.

During the writer's absence in foreign ser-
vice, the patient made two trips to a weil-
known western surgical center, where two
unsuccessful attempts were made to intro-
duce the direct laryngoscope. Inasmuch as
it was impossible to remove the growth sur-
gically, the patient was treated by applying
radium externally. There resulted, however,
no diminution in the size of the growths.

On the writer's return, examination of the

"Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn., Sept. 14-17, 1920.

THE purpose of this paper is to describe
the treatment of intractable papillo-
mata of the larynx with radium. The patient
on whom this was used is now thirty-eight
years of age. Ten years ago she noticed that
her voice showed signs of huskiness; soon a
complete aphonia developed. She was treated
by her family physician and a local laryn-
gologist for a period of two years ; at the
time I first saw her, she had had a loss of
voice for over two years.

Laryngological examination showed that
the lumen of the larynx was occluded with
papillomatous masses. These partially cov-
ered the epiglottis and the false vocal cords.
An attempt was made to remove the neo-
plasm with forceps introduced through the
Jackson laryngoscope. On account of the dif-
ficulty in hyperextension of the neck, owing
probably to shortness of the cervical liga-
ments, it was found impossible to operate
satisfactorily with the direct laryngoscope.
Repeated attempts were made, both under
local and general anesthesia, to obtain a di-
rect view of the larynx, but these were all un-
successful. A number of pieces were removed
by the indirect method of the laryngoscopic
mirror and curved forceps, after which pro-
longed local treatments were given. The
whole category of chemical escharotics

156

Larynx Treated with Radium f(~>r Papillomata

patient showed that the epiglottis was com-
pletely covered on its posterior surface with
villous excrescenses, and the interior of the
larvnx could not be seen, the opening being
bl(3cked bv the growth. Neither the false nor
the true vocal cords could be distinguished.
The patient, at this time, had worn the
tracheotomy tube continuously for a period
of five years. During this time, she had given
birth to two children, with no seeming in-
convenience from the constant wearing of
the tracheotomy tube.

In considering the case from its various
aspects, it seemed futile to attempt further
surgical treatment, and as the .r-ray and ex-
ternal application of radium had been un-
successful, it was decided to attempt the in-
troduction of the radium capsule into the in-
terior of the larynx. The introduction of the
capsule with laryngeal forceps presented cer-
tain difiiculties. as did also the introduction
of the radium capsule on a semi-flexible
bougie. Accordingly, the tracheotomv tube
was removed for a few minutes and a small,
flexible bougie was introduced into the
trachea, the bougie was passed upward
through the larynx and seized bv forceps and
drawn out through the mouth. A strong
thread was then attached and pulled down
through the larynx and out through the
tracheotomy opening. The radium capsvfle,
with its rubber filter, was then attached to
this ligature, and pulled downward bv the
thread until the capsule was seen bv the mir-
ror to be wedged in the superior opening of
the larynx. Twenty-five miligrams of radium
placed in a rubl^er filter were allowed to re-
main in position of one and a half hours. The
patient was given a preliminary dose of mor-
phia to quiet the cough resulting from the
introduction of foreign material in the
larynx. The tracheotomv tube was re-intro-
duced and the lower end of the thread was
attached to the tube, while the upper end of
the thread was anchored to one of the teeth.
In this way, the radium capsule was held im-
mobile during the hour and a half of treat-
ment.

Considerable reaction followed the first
seance, but at examination about one month

later it was fecund that the epiglottis was
practically clear of papillomata. At the sec-
ond seance, the radium capsule was drawn
well down into the larynx, with the dosage of
twenty-five milligrams for one hour. This
was followed by only a mild reaction, and
partial disappearance of the laryngeal
growths. The true and the false vocal cords
then became visible.

A third treatment was given after a period
of two months, with a similar dosage.

After three treatments, the patient's
larynx was practically free of growths, al-
though a few small tags remained, which will
be subject to further irradiation. During the
past week, a letter was received from the
patient in which she states she is now able to
dispense with the tracheotomy tube for one-
half da\- at a time.

In presenting this case for discussion, and
in giving the case history, we believe that we
have, in the intralarvngeal application of
radium, a powerful agent for the destruction
of chronic, recurrent laryngeal papillomata.

From the laryngological standpoint, papil-
lomata may be divided into two great
groups ; first, those which are easily amenable
to surgical treatment and which do not tend
to recur after removal, and, second, those
which show a remarkable tendency to recur-
rence even after the most thorough surgical
removal and cauterization. It is in the treat-
ment of this second group of cases, which
fortunatelv are somewhat rare, that the
above procedure is recommended.

"Rapid and extensive recurrence in his-
tologically benign form is observed especially
in children, and illustrates the remarkable
regenerative powers of the laryngeal epithe-
lium. Laryngotomy and excision or cauteri-
zation has been performed three, four, and
even seven times in a relatively short period
before the disease could be arrested (Wilkin-
son, Lendon, Clubbe). In this group of cases,
radium treatment has given excellent re-
sults." Ewing, X CO plastic Diseases.

From a pureh' theoretical standpoint, ow-
ing to the slight abilitv of the radium rays to
penetrate tissues, it would seem useless to
applv radium externally to the larynx, and

Lar^•nx Treated with Radium for Papillomata

157

this was found to be true in this particular
case. The procedure here recommended, viz.,
the introduction of a stout thread through
the laryngeal and tracheal opening and the
immobilization by this means of the radium
capsule in the larynx, offers we think a prac-
tically sure method of cure of these hitherto
intractable cases.

With regard to the technic{ue employed, it
is necessary thoroughly to cocainize the
laryngopharynx and also the trachea through
the tracheotomy opening. At the same time,
the patient should be given enough anodyne
to keep the cough reflex in abeyance. The ob-
servation of the position of the radium cap-
sule in the larynx was difficult when the ordi-
nary laryngeal mirror was employed. Ac-
cordingly, it was found more practica])le to
place the patient before the fluoroscope and,
after orientation of the shadow of the epi-
glottis and of the glottic opening, the posi-
tion of the radium capsule could be accur-
ately determined. If the capsule was placed
too high, it could be readily drawn down by
traction on the ligature through the trache-
otomy opening. This procedure was found to
be much more comfortable for the patient
and far more accurate than observation with
reflected light. In the introduction of the
bougie, it was found nuich easier to introduce
the bougie from below upward, making use
of the tracheal opening.

Since the employment of the intralaryn-
geal applications in this case, the writer has
had the opportunity of using the radivmi cap-
sule in an advanced case of carcinoma of the
larynx, where a tracheotomv had been per-
formed for the relief of obstruction to
breathing. In this case, it was difficult to in-
troduce the bougie through the tracheotomy
opening up into the larynx. Acordingly, the
tracheotonn- tube was reinserted with the
tracheal end pointing upward, this permitting
the bougie to pass upward into the larynx.

This procedure had to be performed expe-
ditiously, inasmuch as the patient's respira-
tions were, of necessity, cut off.

While the observations on the effect of the
treatment of carcinoma by the radium cap-
sule are as vet incomplete, the fact remains
that it is perfectly feasible to retain in this
way anv desired cpiantity of radium in inti-
mate contact with the diseased tissue for any
length of time desired.

1. Epiglottis.

2. Radium Capsule.

3. Hyoid Bone.

4. Thyroid Cartilage.

5. Chain for Retaining Tracheotomy Tube.

Wiiere it is not desirable to perform a pre-
liminar^• tracheotomy, it is possible to use
an intul)ation tube having a groove cut in its
side for the holding of the radium capsule.
The method described above, of intralar}!!-
geal application is only put forward as a sug-
gestion for treatment in cases where all other
methods have failed.

OBSERVATIONS ON THE BEHAVIOR OF THE NORMAL
PYLORIC SPHINCTER IN MAN*

By C. W. McCLURE, M.D., and L. REYNOLDS, M.D.

BOSTON, MASSACHUSETTS

Tf XPERIMENTAL studies on the physi-
-'-' ological factors influencing the motor
functions of the gastro-intestinal tract and
the relation of these motor phenomena to the
digestion and absorption of food products
have been largely carried out on animals. But
the results obtained from such studies can be
applied only in a general way to the physiol-
ogy' of the digestive tract in man. It follows
that more intimate knowledge concerning
various phases of the physiology of the ali-
mentary canal in man would aid in the in-
terpretation of results obtained from experi-
mental studies of the pathological physiology
of human digestion. For this reason certain
phases of the motor functions of the normal
stomach in man were studied. The present
preliminary report largely deals with work
bearing on the question of "acid control" of
the pyloric sphincter in man.

Cannon elaborated the theory, suggested
by Pawlow among others, that acid con-
trolled the action of the pyloric sphincter in
animals. In epitome this theory is that the
presence of acid in the antrum of the stom-
ach causes relaxation of the pyloric sphinc-
ter, while the presence of acid in the duo-
denum causes the sphincter to contract. The
evidence on which this theory is based was
obtained from experiments carried out on
animals. Phenomena occur in animals which
the theory of "acid control" does not explain,
and for this reason other controlling factors
are assumed to exist. Whether or not acid or
some other factor exerts the principal control
over the pyloric sphincter in man has not
been demonstrated, and with the problem the
present investigation is concerned. The re-
sults obtained by previous investigators will
be discussed later.

The object of the present study has been to
determine :

1. The degree of contraction of the py-
loric sphincter when foodstuffs partially fill
the normal stomach.

2. The behavior of the sphincter relative
to the passage of carbohydrate, protein, or
fatty foods from the normal stomach into
the duodenum.

3. The effect on the pyloric sphincter of
direct application of hydrochloric acid and
sodium bicarbonate solutions to both its
antral and duodenal ends.

These observations of the stomachs of
normal persons were made by means of the
fluoroscope after feeding meals composed of
thick porridge and barium or 140 gm. of
ground lean meat and 4 gm. of barium sul-
phate baked into a loaf, or 120 gm. of
ground fatty bacon, 5 tgg yolks and 40 gm.
of barium sulphate baked into a loaf. The
protein and fatty meals were of constant
bulk and consistency.

I. The degree of contraction of the nor-
mal pyloric sphincter. — That the pyloric
sphincter is closed when fluid food is in the
stomach, except during the periods in which
it opens to permit the ejection of food into
the duodenum, was demonstrated in 191 3 by
Cole. His observations were so readily and
easily confirmed by fluoroscopic studies that
they are now universally accepted. The
authors have confirmed Cole's observations
by means of the fluoroscope a large number
of times. Further evidence that the normal
quiescent sphincter is in a state of contrac-
tion is afforded by the fact that barium mix-
tures can be forced from the stomach into
the duodenum onlv bv the use of consider-

•Read at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn., Sept. 14-17, 1920.

Normal Pyloric Sphincter in Man

159

able pressure on the abdominal wall and only
when the sphincter has opened in relation to
the advance of an antral peristaltic wave.
When this is successful the filled antrum and
first portion of the duodenum are seen to be
connected by a narrow isthmus of barium,
which represents the lumen of the sphincter;
on cessation of pressure this narrow isthmus
disappears.

2. Tlic behavior of the pylorie sphincter
relative to the passage of carbohydrates, pro-
tein and fatty foods from the stomach into
the duodenum. — In the routine clinical .t'-ray
examination of the stomach a carbohydrate
meal consists of 500 c.c. of malted milk solu-
tion in which 90 gm. of barium sulphate are
held in suspension by the aid of potato
starch. The meal starts through the normal
pyloric sphincter immediately or within a
few minutes after it has been ingested. The
normal sphincter opens regularly, as each
antral peristaltic wave approaches, and per-
mits the passage of the barium meal into the
duodenum over a period of about ten sec-
onds. In two young men with normal stom-
achs the same phenomenon occurred after
the ingestion of thick oatmeal porridge
mixed with barium. Except in abnormal con-
ditions accompanied by pylorospasm, open-
ing of the pyloric sphincter at irregular inter-
vals, as described by Cannon in cats, was not
observed. The regular opening and closing of
the pyloric sphincter, except in the presence
of pylorospasm. is so well known that no
further work on carbohydrate meals was
deemed necessary in the present investiga-
tion.

Observations on the behavior of the py-
loric sphincter after the ingestion of protein
food were made on eleven young men, ten
with normal stomachs, one with a quiescent
duodenal ulcer, and one woman whose stom-
ach was normal.

Similar observations were made after the
ingestion of fatty food in six normal young
men. The duration of each experiment varied
from thirty minutes to six hours. In these
experiments the food was seen to pass from
the stomach into the duodenum in normal

amounts as each peristaltic wave approached
the pyloric orifice. By normal amounts is
meant that quantity of barium which passes
through the pyloric sphincter after the in-
gestion of the barium meal commonly used
in an .^'-ray examination for diagnostic pur-
poses. The amounts of foodstuffs and of
water fed in these experiments formed a
verv thick mush when thoroughly mixed to-
Sfether in a mortar. To obviate the criticism
that the consistency of the food permits it to
act more like liquid than solid foods, the
meat and fatty meals were administered
without the addition of water. The result
obtained was the same, namely, the food-
stuffs began to pass through the pylorus
immediately.

Our observations seem to indicate that
both fattv and protein meals begin to leave
the stomach within three to ten minutes after
the food has been swallowed. Furthermore,
the food passes through the sphincter into
the duodenum as each peristaltic wave ap-
proaches the pylorus. The amounts of a sin-
gle food or of different ones which pass
through the sphincter during a given time
do not vary in the same individual.

3. Tlie effect of hydrochloric acid and
sodium bicarbonate solutions on the pyloric
sphincter. — Solutions of hydrochloric acid
and in a few instances of sodium bicarbonate
were introduced into the duodenum and the
effect on the opening and closure of the py-
loric sphincter was ascertained. The behav-
ior of the sphincter was constantly observed
through the fluoroscope. The activity of the
sphincter was determined by the passage or
non-passage of barium from the stomach
into the duodenum.

The subjects used were hospital patients
whose physical condition at the time of the
experiments was considered to be normal.
The usual gastric analyses of these patients
showed no abnormalities.

The observations on the effect of hydro-
chloric acid and sodium bicarbonate solutions
on the pylorus were made as follows: the
duodenal tube was passed subsequent to a
twelve hour fast; the tube was allowed to

i6o

Normal Pyloric Sphincter in IMan

pass into the duodenum. The time required
for the tuhe to pass from the stomach into
the duodenum was variable ; at times it was
only a question of minutes and at others it
required an hour or more. After the tube had
entered the duodenum a meal was fed.

The meal consisted of a meat and barium
meal either rinsed down with 200 c.c. of
water or made in a mush by grinding in a
mortar with 100 c.c. of water. In certain
cases, where the subject was unable to eat
the whole meal prepared, we gave an addi-
tional malted milk, potato starch and barium
mixture to enable us more comj)letely to
visualize the sphincter ; however, this was
necessar}- in only two cases.

After the patient was observed a sufficient
length of time to determine that the peri-
staltic waves were orderly and regular we
began the instillation of solutions of hydro-
chloric acid and sodium bicarbonate. In some
instances an N/40, in others N/20 and in
one case an N/io hydrochloric acid warmed
to body temperature was instilled in from
5 c.c. to 20 c.c. amounts into the first, second
and third portions of the duodenum. The
time of the instillation was varied in relation
to the normal opening time of the pyloric
sphincter. In some cases an injection was
made just prior to the normal opening time
of the pyloric sphincter and this was gauged
by the observation under the fluoroscope of
the advance of an antral peristaltic wave. In
other instances the instillation of 20 c.c. of
the acid was begun as an antral peristaltic
wave reached the sphincter and the instilla-
tion continued until the sphincter had opened
and closed several times. In another series of
experiments a i per cent solution of sodium
bicarbonate was used in place of the acid and
the pylorus w^as similarly observed. In these
experiments on four individuals no effect
was observed on the opening time of the
sphincter, the amounts of barium passing-
through it, or upon its time of closure. It will
be seen consecfuently that the behavior of the
sphincter is the same whether acid or alkali
is introduced into the duodenum. In a fifth
subject the introduction of N/20 hvdro-
chloric acid or of i per cent sodium l)icar-

bonate into the first portion of the duodenum
produced either complete or partial pvloro-
spasm and vigorous duodenal antiperistalsis.
This rather unexpected behavior was subse-
Cjuently explained by the discovery of a duo-
denal ulcer. In a subject the introduction of
N/20 h}-drochloric acid into the third por-
tion of the duodenum produced either com-
plete or partial pylorospasm associated with
the development of very shallow gastric peri-
staltic waves. In one subject a loop of the
duodenal tube passed through the sphincter
into the duodenum leaving the metal tip in
the antral end of the pyloric sphincter. This
permitted solutions to escape from the orifice
of the tube directly onto the antral portion
of the sphincter.

DISCUSSIOK

Our obser\-ations demonstrate that finelv
divided foods, regardless of whether thev
are solid or liquid, begin to leave the stomach
within a very short period of time. Thus
barium was observed to pass the sphincter in
the time required for the subject to ingest
the meal and be prepared for fluoroscopic
observation, w^iich was alw^ays less than ten
minutes. It was of interest to observe that
carbohydrates, fats and proteins behaved
alike in this respect — contrary to what one
would expect from reports of animal obser-
vations. That this phenomenon is true for
carbohydrate meals has already been stated.
But with the exception of Cole no observa-
tions in man of other types of meals have
been published, and his publication unfor-
tunately gives no experimental details. The
barium meal passed through the pyloric
sphincter as each antral peristaltic wave ap-
proached that orifice. Cole has previously
made similar observations. The opening of
the pylorus at irregular intervals, as de-
scribed by Cannon in cats, was not noted. It
was observed that the antral portion of the
stomach was cjuiescent except for peristaltic
waves which at regular intervals swept over
it. The contents of the antrum were conse-
([uentlv not undergoing a mixing process and

Normal Pyloric Sphincter in Man

i6i

the same food must have remained in contact
with the gastric mucosa. Therefore, the sur-
face of the antral mucous memhrane would
be covered with material of a fairly constant
degree of acidity. It is very probable that the
reaction of this material is acid. This state-
ment is based upon the following facts:

1. The authors have found in two sub-
jects, after feeding a meat meal, the food
when first ejected from the stomach into the
duodenum to contain free hydrochloric acid
in the strength of N/60 and N/500. The
position of the metal tip of the duodenal tube
and the phenomena transpiring in the stom-
ach and duodenum at the time the specimen
for analysis was withdrawn were determined
by fluoroscopic observatic^i.

From the abo\ e it follows that in order
for the stimulation of acid in the stomach to
open, and in the duodenum to close the
sphincter, there must be assumed the exist-
ence of a very delicate balance between the
antral and duodenal reflexes in relation to
the presence of the same degree of acidity,
the duodenal reflex being much the more
sensitive.

McClendon and Aleyers and the authors
have found the contents of the first portion
of the human duodenum to l)e either neutral
or of low acidity. After emptying itself of
food just ejected from the stomach the duo-
denum will, therefore, be practically neutral
in reaction, and in the presence of pancreatic
juice possibly alkaline. Then if acid in the
stomach causes the sphincter to relax, the
sphincter should become patent when the
duodenum empties itself of food. That this is
not the case is demonstrated by the difficulty
experienced in pushing barium through the
sphincter into the duodenum by palpation of
the abdominal wall. In fact, it is probable
that barium can be caused to enter the duo-
denum by this means onlv when the sphincter
opens in relation to the advance of an antral
peristaltic wave. From this it follows that, if
the pyloric sphincter is under "acid control,"
then the fact that it (^pens at regular inter-
vals and normallv onlv in a definite relation
to the advance of an antral peristaltic wave
makes it necessarv to assume either ( i ) that

there is a finel\- adjusted acid regulatory
mechanism in the antral region of the sphinc-
ter which produces the proper degree of
acidity to relax the sphincter at a fairly exact
time in relation to the approach of a peri-
staltic wave toward the sphincter; or (2)
that a comparable mechanism for properly
neutralizing the contents of the duodenum
must exist. If either or both such mechan-
isms exist they must be so adjusted as to per-
mit of changes in the rhythm of the time of
opening of the sphincter, as occurred in one
of our experiments after pouring alkali onto
the end of the pyloric sphincter. Further-
more, while the s[)hincter closes suddenly it
remains open an appreciable length of time.
Barium flows thrcnigh the sphincter as an
antral peristaltic wave approaches and con-
tinues to do so until the wave has spent itself.
The sphincter, therefore, does not close as
soon as acid enters the duodenum, and the
presence of acid we have deuK^nstrated ex-
perimentallv. If acid in the duodenum causes
closure of the sphincter then either (i) the
proper degree of acidity must be always de-
^•eloped at a time when an antral wave has
spent itself, or (2) a secondary mechanism
in some wav regulating the reflex must be
assumed.

The existence of the various factors out-
lined are necessary to explain the theory of
"acid control" of the sphincter, and their ex-
istence has not been proved. The assumption
of the. existence of these factors renders the
mechanism of the control of the sphincter
exceedinglv complex. It is possible that some
other less complicated mechanism may exist
in man. The latter has been suggested, but
not proved, hv Luckhart, Phillips and Carl-
son. These investigators found that a rela-
tion exists between the muscular activity of
the antrum and the opening of the sphincter.

In four of the experiments here reported
it has been shown that acid introduced into
the duodenum did not prevent the opening of
the sphincter. These observations do not
support the theory that acid in the duo-
denum causes contraction of the pyloric
sphincter. Furth.ermore. sodium bicarbonate
was poured into the duodenum in a quantity

1 62

Normal Pyloric Sphincter in Man

which, judging from the limited observations
of the degrees of acidity of the duodenal
contents, was sufficient to bring about neu-
tralization. The latter must have occurred in
an experiment in which 5 per cent sodium
bicarbonate solution was allowed to flow into
the duodenum. The carbonate solution was
introduced on two occasions in quantities of
10 c.c. and 20 c.c. after the pyloric sphincter
had opened and up to the time of its com-
plete closure. Before the introduction of the
carbonate solution the ch}-me was collected
as it was poured into the first portion of the
duodenum during the latter half of the time
the sphincter remained open. This allowed
the first portion of the chyme to clear the
region of the metal tip of duodenal contents.
The concentration of free hydrochloric acid
in the chyme was N/500, and of total acidity
N/25 (titrated to phenolphthalein). Accord-
ing to the "acid control" theory, the sphincter
should have remained patent as long as the
duodenal contents in these experiments were
alkaline. This it did not do, but was observed
to close completely. However, absolute evi-
dence that the amount of carbonate intro-
duced > neutralized all the acid in the duo-
denum could not be obtained, although but
little doubt can exist that neutralization was
effected.

CONCLUSIONS

Conclusions drawn from the experimental
work here presented are as follows:

1. Finely divided carbohydrate, protein or
fatty foodstuffs begin to leave the normal
human stomach within from three to ten
minutes after their initial ingestion.

2. Under normal conditions the human
pyloric sphincter opens regularly at the ap-
proach of each antral peristaltic wave, allows
chyme to pass through into the duodenum
during an appreciable length of time, and
closes when the antral peristaltic wave has
spent itself.

3. The introduction of N/40, N/20 or
N/io hydrochloric acid solutions into the
first, second or third portions of the normal
human duodenum either produced no effect
on the opening of the pyloric sphincter as
observed by means of the fluoroscope, or pro-
duced effects which were interpreted as the
result of abnormal irritation of the duodenal
mucosa.

4. Neutralization of the contents of the
first portion of the duodenum did not prevent
the closing of the pyloric sphincter.

5. The experimental results obtained offer
evidence that acid is not the principal factor
controlling opening and closing of the pyloric
sphincter in man.

LEATHER'BOTTLE STOMACH (LINITIS PLASTICA)^

Report of Five Cases with Remarks on Relationship to Syphilis and

Cancer of the Stomach

By LEON T. LE WALD, M.D.

Professor of Roentgenology, New York University and Bcllevue Hospital Medical College;
Director Roentgen Ray Department St. Luke's Hospital, New York;
Director E. N. Gibbs Memorial X-Ray Laboratory, New York

NEW YORK CITY

TN view of the number of recently reported
-■■ cases of syphilis of the stomach, which
simulates in appearance that of the leather-
bottle stomach, it seems advisable to revise
our ideas of the roenti^'en diagnosis of this
condition.

Despite the difficulty of attempting to dif-
ferentiate by roentgen methods alone diffuse
infiltrating scirrhus carcinoma from syphi-
litic infiltration, or fibrous infiltration of the
stomach, it is, nevertheless, possible to dis-
tinguish these cases one from the other in a
large enough proportion of cases at least to
facilitate and augment clinical diagnosis; and
in many instances it is possible to make an
absolutely correct diagnosis when taken in
conjunction with the Wassermann test.

The leading monographs on leather-bottle
stomach have been and are based largely
upon clinical, operative or postmortem evi-
dence; but with the addition of roentgen
methods of study of living pathology, which
permit of diagnosis in life, heretofore not
possible, our knowledge of the subject is
considerably supplemented.

The term "leather-bottle" appears to be
based upon the consistency and thickness of
the stomach wall rather than from any defi-
nite resemblance to our modern bottles;
though the narrowing of the pyloric end of
the stomach and a compensatory widening
of the cardiac end would seem to be the
reason for calling it a "leather-bottle" stom-
ach, after the leathern water bottles of the
early Egyptians. Schrumpf (1876) calls it
"field-canteen" stomach.

Dr. H. H. M. Lvle^ in 191 1 collected sev-

^ Annals of Surgery, Nov. 1911.

*Read at the Twenty-first Annual Meeting of The American

enty cases, described under the term linitis
plastica or cirrhosis of the stomach, and re-
ported a case cured by gastrojejunostomy.
This case has been under observation for
nine years and is still alive, Dr. Lyle informs
me.

Carman^ (1920) has reported three cases.

From our roentgenologic observation of
these cases, it appears that the peculiar type
of stomach to which the term "leather-
bottle" has been applied may represent any
one of three conditions: first, fibromatosis;
second, syphilis ; third, diffuse carcinoma.

Cases "illustrating these three types to-
gether with the roentgen findings are re-
ported below ■.

CASE HISTORIES

Case I. Leatiier-Bottle Stomach Due
TO Fibromatosis. — H. O., female, aged
fiftv. Seven months prior to admission to
St. Luke's Hospital the patient noticed a tu-
mor in the epigastrium, which on examina-
tion was found to be firm, movable and non-
tender. There was no complaint of pain,
vomiting, nausea, sour eructations or jaun-
dice. Solid foods caused gastric distress fol-
lowed by some belching of gas; there were
several bloody stools but no tarry ones; a
loss of forty-five pounds in one year. The
general appearance was that of a fairly well
nourished, not acutely ill woman.

Gastric analysis, free HCl — o, total acidity

—30-

Roentgen examination revealed a d(^form-

2 Carman and Miller. Roentgen Diagnosis, Dis-
eases of the Alimentary Canal. Saunders, 1920.
Roentgen Ray Society, Minneapolis, Minn., Sept, 14'/, 1920.

163

164

Leather-Bottle Stomach

ity of the horizontal portion of the stomach
involving about one third of the stomach
wall. (Fig. i). It was very smooth and re-
sembled closely a specific infiltration. Both
the greater and lesser curvatures were in-
volved. The stomach emptied at an exceed-
ingly rapid rate, the meal meeting with prac-

The stomach practically emptied itself in one
hour. At the sixth hour the meal had reached
the hepatic flexure. A considerable portion of
the meal had been eliminated at the twenty-
fourth hour.

A confirmatory examination showed the
deformitv of the stomach persisting and flu-

FiG. I. Case 1. Leather-Bottle Stomach Due to Fibromatosis.
Eight minutes after meal. Deformity of stomach involving
greater and lesser curvatures. Irregularity at esophageal en-
trance indicating infiltration. Microscopic examination showed
increase in fibrous tissue Imt no evidence of cancer.

tically no delay at the pylorus, so that in five
minutes the small intestine was filled. The
duodenum was slightly dilated. At the car-
diac end of the stomach there was some ir-
regularity about the entrance to the esopha-
gus, suggesting infiltration of this region.

oroscopic examination showed the mass in
the abdomen to be related to the deformity
of the stomach wall.

Preoperative clinical diagnosis: Carcin-
oma of the stomach. At operation the stom-
ach was found infiltrated with a large tumor

Leather-Bottle Stomach

165

mass extending over the lesser curvature
from the cardia to the pylorus. Lymphatics
dilated, but no enlarged or palpable glands;
no epigastric adhesions. Incision made in the
stomach just above the pylorus and two
small pieces removed for microscopic ex-
amination.

Pathologic examinati(^n of the specimen
taken from stomach wall showed consider-
able thickening, apparently in the submucosa.
The mucosa appeared normal and the serous
coat w'as smooth and shining. The smaller
fragment consisted only of mucosa and sub-
mucosa. The latter w-as greatly thickened.
There was no evidence of any gross lesion.

Microscopic examination of the specimen
showed that there was a very considerable
increase in the fibrous tissue of the sub-
mucosa. This was very thick, rather dense,
contained large fibroblastic nuclei which were
w^ell stained and gave the form of cellular
tissue. The mucosa was normal overlying
this, or in some places was slightly hyper-
trophic. Blood vessels were only moderately
thick-walled, showing comparatively little
change. There was no perivascular infiltra-
tion, and only very little infiltration of the
fibrous tissue, except along the deep surface
of the mucosa where there were rather nu-
merous lymphocytes. The pathologic lesion
appeared only as a diffuse overgrowth of
fibrous tissue.

No cells suggestive of a neoplasm could he
detected in the section.

Patient was placed on anti-syphilitic treat-
ment in spite of the negative Wassermann
examination. No improvement resulted.

Roentgen examination five weeks after
operation and about three weeks after the
beginning of treatment showed practically
no change in contour or emptying time of
the stomach. (Fig. 2.)

Eleven months later the patient returned
to the hospital complaining of abdominal dis-
tention of two months' duration, combined
with a svv^elling of the legs for two weeks.
She was able to take only a small amount of
food at a time. There w-as no dyspnea or
cardiac distress; no jaundice, pain or con-
stipation. The lump in the epigastrium was

still present. She gained in w-eight after the
operation but then became so weak she w'as
quite unable to walk.

Physical examination: patient fairly well
nourished and developed ; not acutely ill ; no
cvanosis, jaundice or dispnea. Abdomen was
distended, tense, dull in flanks ; fluid was
present in epigastrium ; irregular, large mass
just above umbilicus; no rigidity. Gastric
analysis: free HCl — o; total acidity — 10.

Fig. 2. Case I. (Same case as Figure i.) Fibroma-
tosis. Five weeks after exploratory- operation and
removal of section. Ten minutes after meal.
Practically no change in contour or emptying time
of stomach.

Fluoroscopic examination showed distinct
delay in the esophagus, indicating spasm or
organic constriction at the cardiac end of the
stomach.

Roentgen examination: the stomach re-
mained very small as noted at previous ex-
amination. The greatest transverse diameter
of the stomach was only 5 cm. This con-
firmed the diagnosis of leather-bottle stom-
ach. Greater curvature 3 inches above the
umbilicus. At the fourth hour, the stomach
was entirely empty. No delay in the ileum.

The colon was sluggish. Most of the meal
remained in the transverse portion of the
colon at the twent}- fourth hour.

At the forty-eighth hour some of the meal

1 66

Leather-Bottle Stomach

had reached the sigmoid. Traces remained in
the transverse portion of the colon.

The abdomen was aspirated and lo c.c. of
fluid removed. No operation. No medication,
except tonic. Rest.

vice of St. Luke's Llospital, New York, by
Dr. Samuel Laml^ert on September 29, 1914,
with a provisional diagnosis of gastric ulcer.
Historv: Patient had suffered from pain
and vomiting for two years with a loss of

Fig. 3. Case II. Leather-Bottle Stomach Due to Syphilis. (Aged
Twenty-three.) Two minutes after meal. Xote diminished size of
stomach with compensator}' dilatation of esophagus and rapid passage
of the meal through the pylorus.

Case IL Leather-Bottle Stomach
Due to Syphilis.^ — M. A., female, aged
twenty-three, married. Case referred for
roentgen examination from the medical ser-

3 This case is one of a group of cases of syphilis
of the stomach reported in American Journal of
Roentgenology, February 191 7, iv, 76, by the author.

fiftv pounds in weight. Four months pre-
viously she had had a therapeutic abortion
performed for persistent vomiting and a
similar occurrence once before that, three
months after her marriage. Whenever she
took food she was seized with a sharp pain
in the epigastrium followed by vomiting in

Leather-Bottle Stomach

167

about fifteen minutes, which reheved the
pain. Test meal: blood, o; lactic acid, o; free
HCl, o; total acidity, 14.

Roentgen examination showed a peculiar
deformity involving the pyloric half of the
stomach. (Fig. 3.) This region appeared to
be infiltrated, together with the pyloric ring
which is held open allowing the food to pass
out of the stomach in a most remarkable
manner. At the sixth hour there was a small
residue high up in the cardiac end of the
stomach. Syphilis of the stomach was diag-

had ceased and weight had been gained.
Roentgen examination showed the peculiar
deformity of the stomach persisting and at
the sixth hour there was a small residue at
the cardiac end of the stomach.

^ larch I, 191 5, patient remarkably im-
proved, had gained forty-four pounds in
weight, and was entirely free from pain and
vomiting. Roentgen examination showed the
deformitv at the pyloric end of the stomach
still persisting and the stomach emptying at
a very rapid rate. (Fig. 5.) At the sixth hour

Fig. 4. Case II. (Same case as Figures 3 and 5.)
Syphilis. (Aged Twexty-three.) Confirmatory
examination. Five minutes after meal.

nosed and a Wassermann examination ad-
vised. It was reported four plus.

On October 5, 1914, a confirmatory ex-
amination was made. This duplicated the
finding of a peculiar deformity involving the
pyloric half of the stomach causing a consid-
erable narrowing of the lumen, an appear-
ance which is characteristic of syphilis of the
stomach. (Fig. 4.) On November 11, 191 4,
another examination was made after the pa-
tient had been placed on anti-spyhilitic treat-
ment following the findings of a positive
Wassermann reaction. Nausea and vomitino"

Fig. 5. Case II. (Same case as Figures 3 and 4.)
Syphilis. (Aged Twenty-three.) Five months
after medical treatment. Ten minutes after meal.
Cessation of symptoms. Increase in size of stomach
with less rapid emptying.

there was a very small residue in the cardiac
end of the stomach, very much as in the
earlier examination.

February 16, 191 6. roentgen examination
showed still further improvement in the size
of the stomach, indicating some absorption
of the infiltration. This was particularly evi-
dent about the pylorus, the sphincter having
regained its function so that food passed
through it at about a normal rate instead
of at the excessive rate previously noted.
She was free from all stomach symptoms

1 68

Leather-Ijottle Stomach

and had gained fifty- four pounds in weight.
November 20, 1916, gave birth to a
healthy child.

Case III. Leather-Bottle Stomach
Due to Carcinoma in a Girl Twenty-
three Years of Age.* — D. \^., admitted to

first there was no nausea or vomiting, but
later it was accompanied by incessant vomit-
ing. There was no blood in the vomitus.
There was marked loss in weight.

Physical examination ; a very poorly nour-
ished adult female, decidedly pale, with
drawn features. Abdomen : there was a mass

Fig. 6. Case III. Leather-Bottle Stomach Die to Carcinoma, in a Girl
Twenty-three Years of Age. Two minutes after meal. Note dilatation
of the esophagus, diminished size of stomach with rapid emptying.
Microscopic examination : carcinoma.

St. Luke's Hospital March 24, 191 9, w^ith a
clinical diagnosis of anemia. Possible cause,
carcinoma of the stomach or splenomegaly.
History, four months ago patient began
to suffer from indigestion, especially notice-
able about one-half hour after meals and
lasting from one to one and a half hours. At

*This is the earliest age in which carcinoma of the
stomach has been observed by the author. A case at
the age of fifteen years is abstracted in the Journal
of the American Medical Association, April 2, 1921.

in the epigastrium extending to the left side
and palpable two inches below the costal
margin. It moved with respiration and had a
very distinct edge. It appeared to represent
either the left lobe of the liver or the spleen.
Wassermann reaction negative. Gastric anal-
ysis: free HCl — o; total acidity — o.

Roentgen examination -. the fluoroscope re-
vealed a most remarkable condition. The
opaque meal passed immediately out of the
stomach. The condition resembled very

Leather-Bottle Stomach

169

closely that observed in several cases of svph-
ilis of the stomach. The opac|ue meal ex-
amination confirmed the fluoroscopic find-
ings of a remarkably small stomach with a
gaping pylorus. So rapid was the emptying
of the stomach that a roentgenogram was
made with extreme difficulty, taken while
the patient was in the act of swallowing and
prone on the table. ( Figs. 6, 7, 8. ) The
stomach as thus outlined measured only
about II by 3 cm. Eight days later a con-
firmatory examination was made with the
patient in the prone position. A partial

under surface of the liver. A jejunostomy
was performed and a tube inserted.

Pathological examination. Specimen re-
moved at operation consisted of a small node
from the greater curvature with considerable
inflammatory tissue surrounding it. It was
verv firm and white on section.

Microscopic examination of the section
showed a considerable amount of inflamma-
torv tissue invading the fat. There was also
a small lymph node which was almost en-
tirely fibrous. This fibrous tissue and fat
were diffusely invaded l)y small epithelial

Fig. 7. Case 111. (Same case as Figures 6 and 8.) Fig. 8. Case III. (Same case as Figures 6 and 7.)
Carcinoma. (Aged Twenty-three.) Six minutes Carcinoma. (Aged Twenty-three.) Eight minutes
after meal. Meal passing rapidly into jejunum. after meal. Stomach almost entirely empty.

filling of the esophagus could be made out,
suggesting some attempt at compensators-
dilatation to make up for the small-sized
stomach.

The patient was operated upon April 23,
1919. The duodenum, pylorus and distal inch
of the stomach were apparentl)' normal.
Proximal to this was a lump which was
sharply marked by a hard indurated line. The
stomach was contracted and the walls were
the seat of nodular induration which felt
carcinomatous to the operator. Surrounding
the stomach there were a few hard nodes.
The stomach was closelv adherent to the

cells growing singly or in slender tubules ap-
parently in the lymph vessels. Thev were
only moderately hyperchromatic, the nuclei
were rather large in proportion to the size
of the cell, although the entire structure was
comparatively small. Some of the blood ves-
sels were very thick-walled and the coats
were extensively invaded by these small cells.
The fat appeared to be actively growing since
there were numerous nucleated cells with a
pale cytoplasm as well as fat vacuoles with-
out nuclei. Diagnosis: Carcinoma in inflam-
matory tissue from greater curvature of
stomach.

170

Leather-Bottle Stomach

In spite of the operative procedure the pa-
tient continued to lose weight and strength
and died two weeks later. Autopsy revealed
cancer of the stomach and the following
notes were extracted from the autopsy rec-
ord: The neoplasm began at the cardia. The
cancer extended along the lesser curvature
and stopped short about 3 cm. above the

toneum, but the exact site of the original tumor
could not be determined. It probably originated
in the stomach. The history is as follows:]

Case IV. Leather-Bottle Stomach
Probably Due to Carcinoma. — C. M.,
male, aged fifty-six. Has complained of
stomach trouble for nine months; suffered

Fig. 9. C.^SE III. Caulinuma of the Stomach. (Ac.ed Twenty-three.)
Photograph of stomach showing diminished size and thick wall.

pyloric opening. The lesser curvature was
greatly thickened. The omentum was firmly
fixed to the greater curvature and a little of
the fundus remained free from the growth.
The pancreas was adherent to the stomach
and on section appeared to be normal. The
stomach was contracted, measuring but 10
cm. in its vertical axis. (Fig. 9.) The liver
showed no evidence of metastatic involve-
ment.

[A fourth case of a very similar-shaped
stomach has been encountered and explored
surgically and the microscopic examination
showed the presence of carcinoma of the peri-

from vomiting and pain in the abdomen. Ad-
mitted to St. Luke's Hospital, July 12, 1919,
under the service of Dr. Nathan Green.

Roentgen examination revealed a remark-
ably small stomach, measuring about 12 by
4 cm. in diameter. (Fig. 10.) The pylorus
was gaping so that the duodenum and upper
jejunum were filled within a few minutes.
There was secondary dilatation of the
esophagus. The findings were typical of
leather-bottle stomach and closely resembled
cases of syphilitic infiltration of the stomach
wall. Wassermann was negative.

Exploratory laporotomy was performed

Leather-Bottle Stomacli

171

July 22, 1919, by Dr. Green. The abdomen the carcinoma. Both the stomach and the

was markedly clistended. There was free transverse colon were infiltrated with the

fluid in the peritoneal cavity. The intestines new growth. The liver was hard and nodular

were matted together owing to numerous and studded with metastatic nodules. A sec-

FiG. 10. Case IV. Leathfj^-Bottle Stomach Due Probably to Carcinoma.
Fifty minutes after meal. Xote small size of stomach with compensatory
dilatation of esophagus. Pathologic examination : metastatic carcinoma
from abdomen; origin of growth not evident.

adhesions and covered by minute carcino-
matous growths. The stomach and transverse
colon were matted together so that it was
impossible to determine the primar)- seat of

tion was removed for microscopic examina-
tion from the infiltrated omentum.

Microscopical examination reported by
Dr. L. C. Knox. Section consisted of fatty

172

Leather-Bottle Stomach

tissue with extensive prockictive inflamma-
tion and large collections of lymphocytes,
and throughout this a few infiltrating car-
cinomata cells. The cells were rather small
and were found in small groups onlv, but
the nuclei were large, hyperchromatic. and
showed numerous mitoses. There was no
tendency to form glands and no evidence as

aged sixty-three. The patient had suffered
from vomiting for several months; no food
in the vomitus. just mucus and apparently
bile. The vomiting had become almost con-
tinuous and was without relation to the tak-
ing of food. It was impossible to obtain
stomach contents for a gastric analysis. (The
reason for this is verv evident in view of the

Fig. II. Case \'. Le.\ther-Bottle Stomach Due to Carcinoma (?).
Twenty-five minutes. Note small size and dumb-bell shape, very rapid
emptyin.L; and compensatory dilatation of esophagus.

to the possible origin of the growth. Diag-
nosis: Metastatic carcinoma from abdomen.
Discharged from the hospital August 7.

1919-

[Note: Just prior to publication of this
article an additional case of leather-bottle
stomach has been observed. The history is as
follows:]

Case V. Leather-Bottle Stomach
Due to Carcinoma (?). — C. AL, female.

rapid emptying of the stomach shown radio-
graphically. ) Wassermann negative.

Roentgen examination: the lower end of
the esophagus showed slight dilatation.
( Fig. II.) The stomach was exceedingly
small and dumb-bell shaped. (Figs. 12. 13.)
The pvlorus was gaping so that the entire
duodenum and upper jejunum were imme-
diately filled. Moderate dilatation of the
duodenum suggested some tendency to com-

Leather-Bottle Stomach

173

pensation for the small size of the stomach.
Roentgen diagnosis: leather-h(^ttle stomach
— cause not evident.

A confirmatory examination made three
davs later showed the same appearance. Xo
abnormality of the colon observed.

On account of the continuous vomiting the
patient begged for operative relief. ^larch
II, 1921 (two weeks later) a jejunostomy
was performed by W. A. Downes. At op-
eration the stomach was found to be greatly
reduced in size and capacity, giving a typical

CONCLUSIONS

1. The cautious roentgenc^logist, on en-
countering a case showing the typical appear-
ance of leather-bottle stomach, will do well
to report his findings in detail, but reserve
his final diagnosis, stating that the case may
be one of three things:

(a) S}'philis of the stomach.

(b) Diffuse carcinoma r)f the stomach.

2. The terms "linitis plastica" and

Fig. 12. Case Y. Leather-Bottle Stom.ach Due to
C-'XRCixoM.v (?). Twenty-eight minutes. Dilatation
of duodenum compensating for small size of
stomach.

Fig. 13. C.\SE \'. Leather-Bottle Stomach Due to
Carcixom.v (?). Thirty-two minutes. Note dumb-
bell appearance still persisting.

leather-bottle appearance. The walls were ex-
tensively involved in what appeared to be a
diffuse carcinoma. In the middle of the lesser
curvature was a contracted area which sug-
gested the site of a previous ulcer. No evi-
dence of secondary nodules in the liver or
lymph nodes, so that no material was ob-
tained for microscopic examination.

Further report of this case may be made
later.

"leather-bottle stomach" may well be re-
tained as descriptive of this type of deform-
ity of the stomach, but with a full apprecia-
tion of its triple nature.

DISCUSSION

Dr. A. F. Holding. In discussing this paper,
we (Jackson Clinic) happen to have a case of
linitis plastica hypertrophia chronica, and I
thought I would show you the slides and trace
the development of this case, which as far as I

174

Leather-Bottle Stomach

know is unique in that it has been under .i*-ray
observation since its start. This case was ex-
amined first in December, 1919, and a filUng
defect demonstrated. I reported a "filUng de-
fect which was suspicious," and suggested a
re-ray. Dr. James A. Jackson and I examined
the patient together fluoroscopically. We got a
perfect outhne of the stomach, so we thought
that the defect previously seen was due to
spasm or to pressure of the spine, or some-
thing like that. There was no tumor palpable.
The case was discharged with instructions to
report at the end of three months. At the end
of eight months, I found the case had gone to
the University Clinic, and that they had made
an A'-ray examination. Dr. R. H. Jackson was
asked for a surgical opinion, and we asked to
see the plates. These plates showed a filling
defect, constant, which we thought was car-
cinoma. At this time, there was a palpable
epigastric tumor.

This shows the development of this case —
eight months before we found first a filling
defect, and then were able to exclude it — for
by the administration of antispasmodics, we
had a normal stomach shadow — no palpable
tumor. Eight months later — large, typical, con-
stant filling defect — palpable epigastric tumor.

The cas.e was operatef^by Dr. R. H. Jackson,

and a pylorectomy done. After taking the
tumor out he said it cut rather "funny," that
it showed a cheesy consistency, and did not
cut like a typical carcinoma, that when he cut
through it, it creaked like leather. So the
specimen was sent to the Alayo Clinic, and
they reported back a topical case of linitic
plastica. Through the kindness of Dr. Broders,
I have been able to obtain slides and photo-
micrograph of the case, which are here pre-
sented. I am indebted to Dr. Curl for the
privilege of showing some of these plates.

Dr. L. T. LeWald. A question has been
brought up which is still under discussion by
pathologists. For example, Dr. Ewing, I be-
lieve, takes the stand that all linitis plastica
cases are malignant, with the idea that they
are carcinomatous, that if you search hard
enough, you will find carcinoma cells. How-
ever, other pathologists do not agree with this,
and among a series of sixty cases reported by
Dr. Lyle, you will find statements like the
following: "Linitis plastica, malignant type;
linitis plastica, benign type," etc. Case I is run-
ning a course toward a fatal determination,
but whether due to the gastric stenosis or to
malienancv is not definitelv known.

SELECTIVE ORGAN STIMULATION BY ROENTGEN RAYS

ENZYME MOBILIZATION

By WILLIAM F. PETERSEN, M.D., and CLARENCE C. SAELHOF, M.D.

Department of Pathology and the Laboratory of Physiological Chemistry, University of Illinois,

College of Medicine,

CHICAGO, ILLINOIS

A MONG the numerous biological phe-
-^^ nomena which have been studied in
connection with .r-rays and other radiant
agents, the effect on enzymes has received
considerable attention. Usually such studies
have been made by subjecting enzymes in
vitro to rays of varying intensity. The opin-
ion has been repeatedly expressed that intra-
cellular enzyme activity must be altered fol-
lowing the raying of tissues, and a number
of observations have been recorded which re-
late to this subject. Thus Heile^ believed that
the destruction of the leucocytes would lib-
erate large amounts of proteolytic enzymes
and that these liberated enzymes would then
be able to attack other tissues. Neuberg,"
who worked with the effect of radium on
tumors, formulated his ideas in the follow-
ing manner. The radiation causes a destruc-
tion of all the enzymes which have to do
normally with the anabolic processes of the
cell, while those that bring about autolysis
are not altered. He showed that rayed car-
cinoma tissue autolyzed more rapidly in vitro
than unrayed tissue. A number of other
workers have reported experiments similar
in character (Packard, Heile, Wohlgemuth,
etc.).

So far no experiments have been reported
which deal with the actual demonstration of
alterations in the titer of the serum enzymes
after A"-rav or similar stimulation. Lender the
circumstances we thought it would be of in-
terest to determine (a) whether such an
alteration in titer does take place, (b)
whether variations in the serum enzymes
take place when different organs are stimu-
lated, and (c) the influence of different de-

grees of stimulation on the alterations m
titer.

In our experiments w^e have used dogs
rather than the smaller laboratory animals.
The larger serum amounts can be withdrawn
from them for study without injury ; the
normal serum enzyme titers more closely
resemble those obtained in the human, and
in smaller animals the raying of organ
groups is technically much more difficult and
uncertain. Even in dogs it is of course im-
possible to confine the rays to any one organ,
so that when the liver area is rayed, parts
of the pancreas, the gastro-intestinal tract,
etc.. will necessarily be included to some
extent and the results must be interpreted
with this consideration in mind. In our pre-
liminary experiments we used large doses
(Coolidge tube, lO inch distance from the
skin, 8 ma., 5 to 8 inch back-spark without
filter) for periods ranging from fifteen min-
utes to one hour. \\"ith the shorter periods of
exposure we found that raying of the liver
and intestinal areas resulted in some mobili-
zation of enzymes, but that following the
longer periods the titer of the enzymes
diminished. \Nt then proceeded with a filter
(4 mm. aluminum) and reduced the time of
exposure to the following periods — five min-
utes, ten minutes and twenty minutes, the
latter with and without a filter. When so
rayed, considerable alterations in the serum
enzymes could be determined depending on
the area rayed and on the duration of the
exposure.

Our studies on the dogs included the nitro-
gen secretion, the non-coagulable nitrogen of
the serum, the leucocyte and differential
count, the coagulation time of the blood, the
titer of the serum protease, peptidase, este-
rase (lipase), diastase, the anti-trypsin, and
the complement titer. During the course of

1/5

1/6

Selective Org-an Stimulation bv A'-Ravs

the experiments a number of dogs were used
for each regional exposure, but in the accom-
panying chart the average for two dogs has
been used.

Nitrogen Excretion. — The animals were
kept in metabolism cages and on a fixed
diet. With the exception of the periods fol-
lowing the longest liver exposures there was
no apparent increase of nitrogen excretion
following the .r-ray periods in the course of
the experiments. Following the twenty min-
ute exposure of the liver area the average
nitrogen excretion was, however, increased
approximately 60 per cent for a period of
four days following the exposure.

Non-coagulahlc nitrogen of the scrum. —
This was altered to a considerable extent
only following raying of the liver area where
an increase of as much as 50 per cent was
occasionallv determined after raying for ten
minutes or more. This increase persisted for
several days in such animals. Hall and
Whipple " in their experiments with lethal
A--ray doses obtained such increases with
considerable regularity.

The Leucocyte Count. — The leucocytic
reaction showed considerable differences
with thetlifferent regions stimulated. In the
following tabulation the normal count taken
before the .r-ray exposure is contrasted with
the average of the counts obtained for the
one-half hour, one hour, five hour, twenty-
four hour, forty-eight hour and seventy-two
hour periods:

Chart I

Liver

Stlccii

IiitiW'tiiic

Normal 4,000

10,000

3,000

After 5 mill.

Exposure

7,600

16,700

3,400

Before 3,200

14,200

3,000

After 10 mill.

Exposure

5.600

13,400

8,200

Before 3400

11,400

7,400

After 20 mill.

Exposure

10,000

11,300

12,900

Before 4,800 I3,700 14,300

After 20 mill.

Exposure 8,100 14,300 17.450

(without filter)

In Chart I the eft'ect of the raying on
the leucocytes is graphically apparent. It
will be observed that following the raying
of the liver there resulted a leucocytosis of
transient nature; following raying of the
intestinal area the effect of raying was a
step-like increase until a relatively high
leucocytosis (15,000) was maintained. The
two dogs used for the spleen experiment
commenced with a relatively high leucocyte
count (as well as a high serum enzyme
titer) and raving did not materially alter
the count. The commonly observed leuco-
penia that follows raying in the human was
not observed in this series of animals with
the doses that we employed.

Differential Count. — Following the raying
of the hepatic area three of four dogs ob-
served showed a well marked eosinophilia.
This ranged from 5 per cent to 20 per cent
and persisted for a number of days after the
exposure. Raying of the intestinal area and
the splenic area resulted in general in a
diminution of the mononuclear elements and
a relative increase in the polymorphonuclear
cell forms.

Blood Coagulation. — A number of Euro-
pean observers have recently discussed the
increase in coagulability of the blood which
they have observed after raying of the
spleen. Our observations were made with
the capillary tube method and gave us a nor-
mal clotting time that varied between three
and four minutes. Promptly following the
raving of the animals this was usually re-
duced from one to two minutes, the blood
clotting so rapidly that the bleeding of the
animals was at times very difficult. In our
series there seemed very little difference
whether the splenic or hepatic or intestinal
area was rayed, the result being apparent no
matter what region was stimulated. In
studies reported in the following paper it was
found that an increase in the thromboplastic
substance as well as an increase in fibrinogen
occurred after the raying.

The Serum Encymes Protease. — The pro-
teolytic titer of the serum was estimated by
the chloroform method which has been de-
scribed elsewhere.^ While open to objections,

Selective Orgfan Stimulation bv A'-Ravs

177

it nevertheless seems to give a fair index of
the proteolytic capacity of the blood. As will
be observed in the chart (the nitrogen digest
of the serum is expressed in i/io milli-
grams), raying of the hepatic area increased
tlie serum proteases after the ten minute ex-
posure and the twenty minute exposure. The
long exposure when unscreened was no
longer effective. Protease appeared in the
serum after raying the intestinal area, too,
while raying the spleen seemed in general to
be followed by a diminution of the originallv
high titer.

Peptidase. — Peptidase was titrated by al-
lowing varying dilutions of serum to digest
Witte peptone and determining the libera-
tion of tryptophan by means of the simple
bromine color reaction. Normal dog serum
contains practically no peptidase ; after ray-
ing the liver the enzyme makes its appear-
ance but never to the extent that was ob-
served after raying the intestinal area. Ray-
ing of the splenic area was never followed
by such mobilization.

Lipase. — Serum esterase was determined
by incubating eth}-l butyrate with serum and
titrating the resulting formation of acid by
means of 1/50 NaOH. iModerate doses of
.r-rays seem to mobilize this enzvme after
raying the he|)atic as well as the intestinal
area ; raying of the splenic area, on the
other hand, seemed to cause a gradual reduc-
tion in the amount of lipase in the serum.
This was not, however, a constant finding
in all of our animals, for in some raying
of the spleen was at times followed by a
well-marked mobilization of lipase, especiallv
following a single dose of moderate
intensity.

Serum Diastase. — The titer of the serum
diastase was determined with the Wohlge-
muth method of starch digestion by varying
dilutions of serum, and the titer is expressed
in units (24 hour digestion). Raying of the
hepatic area was usually followed by a short
sharp rise in the diastase curve. In the chart
this does not become apparent because the
average for the six bleedings after the x-ray
exposure w^as not greatly altered. Raving of
the intestinal area did not gfenerallv influence

the titer, while raying of the splenic area was
followed rather by a diminution.

Coinpleinent. — The complement titer
(hemolytic titer) w^as followed in a number
of animals, but seemed unaffected by the
rays in the dosage that we employed. (Not
charted.)

Anti-ferment. — Fluctuations in the titer of
the serum anti- ferment were quite marked.
As a rule the titer increased for a short time
following the exposure, then diminished and
gradually increased again for from forty-
eight to seventy-two hours. The most marked
effect followed the more intense periods ex-
posure. (Not charted.)

DISCUSSIOX

\\'hile the clinical development of the
.r-rav and the related radiant agents has been
confined largely to the field of diagnosis and
local therapeusis, the possibility of remote
therapeutic effect has not been uninteresting
to medical observers. Among them Edsall
and Pemberton ^ endeavored to utilize the
effect of the .r-ray in stimulating autolytic
processes by their effort to hasten the auto-
Ivsis of unresolved pneumonia by means of
-I'-ra}'. Since their publications a number of
observers have apparently sought similar ap-
plications. Perhaps the work of Manukhine ®
is of particular interest in this direction.
Manukhine, aware of the influence that the
spleen seems to have in favorably influen-
cing the course of a tuberculous process,
found that when he rayed the spleen of
tuberculous animals (and patients) the tu-
berculous process improved. When, on the
other hand, he rayed the liver the tuberculous
process rapidly extended. He sought to ex-
plain the result because of the differences
that follow in the leucocytic reaction with
the different organs stimulated. \Miile this
is not to be excluded, we are nevertheless of
the opinion that other factors must be taken
into consideration, among them the effect of
the serum enzvmes which as we have shown
in these studies takes place after .r-ray
stimulation.

Other observers besides Manukhine have

Selective Orran Stimulation bv A'-Ravs

taken advantage of the remote effects of
-f-ray stimulation to bring about therapeutic
effects. Drey and Losser ' have but recently
called attention to the effect of splenic .r-ray
stimulation on bronchial asthma, an effect
first observed by Schilling;^ Stettner " has
used the stimulating property of .t'-rays in
increasing healing and ossification and has
also made the application in the stimulation
of glands of internal secretion, as for in-
stance in raying the head to stimulate the
hypophysis to promote growth.^" Stephan's "
w^ork in studying the effect of splenic raying
on the blood coagulating mechanism will be
discussed in the following paper.

The regional stimulation of the abdom-
inal organs such as we have reported in this
paper may perhaps be of some significance in
the study of the intoxications brought about
by -I'-rays and similar agents. Using small
laboratory animals Denis, Martin and
Aldrich ^- found that intoxication was de-
pendent on exposure of some part of the
gastro-intestinal tract and they are of the
impression that the intoxication is closelv
concerned with a reduction of the alkali re-
serve found by them following raying of
intestinal areas. Hall and \Miipple ^ regard
the intoxication as a protein intoxication fol-
lowing injury of the gastro-intestinal mu-
cous membrane. If the effect is in the nature
of a non-specific protein intoxication we
must keep in mind that some of the remote
therapeutic effects occasionally observed mav
be closely related to non-specific therapeutic
results obtained by other means, such as vac-
cine, proteose, milk or tuberculine injections.

If pathological lesions are to some extent
influenced bv the serum enzvmes it would

seem to us possible that through .r-ray organ
stimulation or stimulation by other related
agents a means of such therapeutic control is
offered. We are of course at the present time
unable to state definitely whether the metab-
olism of the normal cell is altered b}^ the al-
teration in titer of serum enzymes ; but where
we deal with necrotic tissue it would seem
plausible that an increase of the proteolytic
serum enzymes w^ould hasten the removal of
such material provided that other factors
that influence digestion (hydroxyl-hydrogen
balance, anti-ferment concentration, etc.) are
favorable. It might seem of interest to keep
such enzyme mobilization in mind when
studying the remote effects of radiant agents,
not only where we have to deal with toxic
manifestations (.r-ray shock, etc.) but also
where favorable therapeutic influences are
made manifest.

BIBLIOGRAPHY

1. Heile. Zfschr. f. klin. Med., 1904, iv, 508.

2. Xeuberg. ZtscJir. f. Krchsforsch, 1904, ii, 171.

3. Hall and Whipple. Am. J. M. Sc, xgig, clvii,

453-

4. JOBLING, J. W., EgGSTEIN, A. A., AND PETERSEN,

W. F. J. Exper. M., 1915, xxi, 239.

5. EnsALL Axn Pemberton. Ain. J. M. Sc, 1907,

cxxxiii, 286 and 426.

6. Maxukhine, J. J. Russky Vratch, 1914, xv, 617.

7. Drey, L., and Losser, H. Strlililcntherapie, 1920,

X, 1052.

8. Schilling, T. Vcrhandl. d. 23tcn Cong. f. innere

Med., April 23, 1906, p. 436.

9. Stettner. Miuicheii. vied. IVchnschr., 1919, Ixvi,

I3U.

10. Stettner. Miiiichcii. iiicd. IVchnschr., 1919, Ixvi.

11. Stephan, R. Miinchcn. iiied. IVchnschr., 1920,

Ixvii, 309.

12. Denis, Martin and Aldrich. Am. .J. Med. Sc,

1920, clx, 555.

THE INFLUENCE OF X-RAY ORGAN STIMULATION ON
THE COAGULATION MECHANISM

By clarence C. SAELHOF, M.D.

Department of Pathology and Laboratory of Physiological Chemistry, University of Illinois,

College of Medicine

CHICAGO, ILLINOIS

DURING the experimental observations
on the effect of the x-ray exposure of
the hepatic, splenic and intestinal areas for
varying periods of time as reported in the
preceding paper, evidence of a change in the
coagulation time of the blood was obtained.
A number of recent investigators, observing
the reduction of the coagulation time follov^-
ing the raying of the splenic area have sug-

extensive loss of blood. The essential factor
that arrested and cured the hemorrhagic ten-
dency was the increase in the quantity of the
coagulating ferment, and this was realized
by the action of the roentgen rays on the
spleen. He thinks they exert a specific func-
tional stimulus on the elements of the spleen
other than the lymph follicles. The blood
platelet count does not seem to be modified.

Norniai normal — i -■ l i ■=

l/2hr. 1 5 24 48 72 1/21. I 5 24 49 7-a V '^ *"^ J. 5 24 4e 73

Chart I. Coagulation Time of the Blood after A'- Ray Exposltre egr Five, Ten and Twenty Minutes.

gested that measure for therapeutic use in
cases of severe hemorrhage. Stephan ^ for
instance reports a case of purpura fulminans
in a man of forty-five in which a refractory
hemorrhagic diathesis was successfully com-
bated early in 191 9 by means of deep roent-
genotherapy applied to the spleen. Investiga-
tions that he undertook in connection with
this result led him to state that roentgen
radiation applied to the spleen rapidly de-
creases the coagulation time of the blood in
vitro, and increases likewise to a consider-
able extent the amount of coagulating fer-
ment in the blood serum. Radiation seems
to have the same effect on the orranism as

The coagulation time was shortened some-
times to one fourth even in normal subjects
by raying the spleen ; the maximum effect
was apparent between the second and fourth
hours, and then gradually subsided. His
clinical and experimental research demon-
strated, he believes, that stimulating the
functioning of the spleen by roentgen ra-
diant energy must be regarded as theoreti-
cally a true physiologic method of arresting
venous and parenchymatous hemorrhages. In
numerous cases it proved extraordinarily ef-
fectual in practice, far surpassing the effect
of any medical hemostatics.

Jurasz " considers this observation of con-

179

i8o

Influence of A'-Rav Ors^an Stimulation on Coasfulation

siderable practical importance in surgery, and
recommends that before operative proced-
ures the coagulation time of the patient be
determined, and if it is found delayed, that
the patient be rayed from fifteen to twent)
hours before the operation in order that the
coagulation time be brought within normal
limits.

As a matter of fact it is probable that an}-
stimulation of the spleen results in this same
effect on coagulation. Thus Nonnenbruch
and Szyszka " found that simple diatherni)
of the splenic area would appreciabl) in-

might simulate the results obtained when
there is an actual increase in the thrombin.

In view of the practical importance of the
subject we have made a detailed study of the
alterations that occur in the coagulation
mechanism following ra}ing of the hepatic
intestinal and splenic area. The observations
included the following: clotting time; pro-
thrombin; antithrombin ; fibrinogen; blood
platelets.

Prothrombin and antithrombin determina-
tions were performed according to the
method of Minot.** Thrombin was prepared

iiiiiiiiiSS

Chakt II. ^iF..\\\ LiXE — Titer after raying hepatic area; Dotted Line — Intestinal area;
Light Line — Splenic area.

crease the coagulability of the blood in from
one to two hours. The effect was, of course,
not quite so pronounced as following radia-
tion. Szenes* found that the increase in co-
agulation occurred not only after raying the
spleen, but after raying lymphatic tissues
in general.

In a more recent publication Stephan ^
takes exception to the work of Szenes, how-
ever, for the reason that his observations
were limited wholly to the measuring of
the coagulation time, not to a study of the
individual factors in the coagulation balance.
Thus a lowering of the antithrombin con-
tent, or an increase in the platelet count

according to Howell.' Fibrinogen determina-
tions were recorded according to Wohlge-
muth.* Blood platelet counts were observed
by the Wright-Kinnicut method.

Dogs were exposed for lo minutes (Cool-
idge tube, screened by a 4 mm. aluminum
screen, at 10 inch distance, 8 ma. and 5 inch
back-spark) over the liver, intestinal and
splenic areas. The exposures were made in
the morning (serum samples being obtained
before) one-half, one, five and twentv-four
hours after exposure.

Blood Coagulation. — In studying the
coagulation time, capillary tubes drawn out
to a uniform diameter were used, the clotting

Influence of .Y-Ray Organ Stimulation on Coagulation

r8i

-5 o

u: o

^ be

o <u

^ 2
^1

t>.

^ IT)

-. a^

.— r^ en

= 2 .=
•^ "C '^

S .5

1 82

Influence of A'-Rav Ors^an Stimulation on Coae^ulation

time recorded when on breaking the tube a
firm coagulum could be drawn out. In our
experiments the most prompt effect on the
clotting time seemed to follow raying of the
lower intestinal tract ; the effect on the clot-
ting time following exposure of the splenic
area was more delayed. In the later case,
however, the effect on the coagulation
especially after longer raying periods was
more prolonged. In Chart I the average
coagulation time is shown.

In view of the rather decided changes in
the coagulation time above noted we anti-
cipated marked alterations in the titers of
the coagulating factors in the blood, corres-
ponding to the observations of Stephan. In
this we were disappointed. As will be ob-
served in the next chart (Chart II) fluctua-
tions in the various elements of the balance
did occur but not to the extent demanded by
the marked lowering of the actual coagula-
tion time.

Blood Platelets. — Raying of the hepa-
tic area gave a maximum increase of blood
platelets during the one half to one hour
period, gradually returning to normal. Ray-
ing of the splenic and intestinal areas gave a
gradual diminution in the platelet count dur-
ing the ensuing time periods.

Prothrombix. — Exposure of the liver
showed a slight decrease up to the one-half
hour sera, with gradual increase in the re-
maining sera, while the spleen and intestinal
exposures showed an increase with a subse-
quent return to normal. (The curve, Chart
II, in which the serum dilutions are charted,
represents the inverse of the actual titer of
the prothrombin present in the serum. Thus
the actual amount following hepatic raying
after a slight diminution, was increased, as
was also the case after raying the splenic and
intestinal areas.)

Antithrombix. — Raying the intestines
showed a maximum increase during the one
to five hour periods ; splenic raying showed
a slight increase through to the twenty-four
hour sample, while raying of the hepatic area
showed a miximum increase during the one

Fibrinogen. — The maximum increase in
fibrinogen from intestinal raying was noted

in the one and five hour period, diminishing
to below normal in twenty-four hours. The
splenic raying was followed by a decrease
with a maximum increase at the five hour
period, returning to normal at the twenty-
four hour period. Liver raying showed tran-
sitory increase with fluctuating decrease and
increase to below normal as noted in
Chart II.

CONCLUSIONS

1. Raying of the splenic area in dogs is
followed by a diminution in the clotting time
of blood determined by the capillary tube
method.

2. Raying of other areas (hepatic and in-
testinal) is also followed by similar changes
in the clotting time. The mechanism of the
alterations in clotting time may differ fol-
lowing various regional exposure. Thus ray-
ing of the splenic area was followed by an
increase in prothrombin, some increase in
antithrombin, a rather delayed increase in
fibrinogen, with little alteration of the plate-
let count. Raying of the hepatic area was fol-
lowed by a rather considerable increase in
platelet count ; raying of the intestinal area
by an increase in the amount of fibrinogen.

3. Inasmuch as the effect of the ;r-ray ex-
posure is Cjuite prompt the use of this
measure in surgical cases as well as in the
management of medical cases associated with
a hemorrhagic diathesis seems a feasible pro-
cedure. The clinical success of the .I'-ray in
the treatment of uterine hemorrhage may
depend in part on the general effect on the
coagulation mechanism.

BIBLIOGRAPHY

I Stephan, R. Miinchen. vied. Wchiischr., 1920, Ixvii,

.309.

2. JuRASZ, T. A. Zcntralbl. f. Cliirg., 1920, xlvii, 824.

3. NONNENBRUCH, N., AND SzYSZKA, W. MuHchen.

iiied. IVchrschr., 1920, Ixvii, 1064.

4. SzENES, A. Miinchen. nicd. W'chnschr., 1920, Ixvii,

992.

5. Stephan, R. Miinchen. incd. W'chnschr., 1920,

Ixvii, 992.

6. MiNOT, Denny and Davis. Arch. Int. Med., 1916,

xvii, lOi.

7. How^ELL. Am. J. Physiol, 191,3; xxxii, 264.

8. Wohlgemuth. Grundriss der Fermcntmethoden,

Berlin, 1913.

AN X-RAY BURN OF THIRD DEGREE FOLLOWED
BY RAPID HEALING*

By EDWARD S. BLAINE, M.D.

Roentgenologist to Cook County Hospital; Instructor in Roentgenology
Northwestern Medical School

• CHICAGO, ILLINOIS

AN UNUSUAL case of rapid healing of
an extensive .f-ray burn seems of suf-
ficient interest to .t'-ray therapeutists to war-
rant its formal presentation in detail. Lest
the surprising occurrences hereinafter de-
scribed be doubted by those whose .r-ray ex-
periences have brought them into contact
with similar reactions of unwished for de-

this superficial skin destruction will be fol-
lowed by healing which takes several weeks
(sometimes months) and disappears, leaving
little or no scarring. In some cases such reac-
tions become a serious consideration to the
therapist if the healing process be unusually
slow. Through accident, an overdose may be
so severe as to result in a third degree reac-

FlG. I.

gree with less favorable results, photographic
evidence is offered as part of the record.

Experience in jr-ray therapy in skin dis-
eases teaches that the first degree reaction is
often necessarv to bring about a cure in
many conditions; it is usually a transitory
condition, a reddening or blushing, which
soon fades, the skin returning to normal. Oc-
casionally a second degree reaction occurs,
in cases in which a first degree change was
desired. This often follows an overdose
through misjudging the patient's resistance
to JT-ray action. Depending on the size of
area involved and the individual's resistance,

♦Read by title at the Twenty-first Annual Meeting of The American Roentgen Ray Society, Minneapolis, Minn

183

Fig. 2.

tion or burn. This third degree reaction is a
far more serious event than the preceding
and most often results in a train of develop-
ments which gives the ;r-ray therapist im-
measurable worry and often mental anguish,
as there is so little that one can do for the
relief of the condition. The degree of skin
and underlying tissue destruction is so great
that some such cases will never heal and re-
course to skin grafting is necessary. The tis-
sue destruction may extend through the
deeper muscles and reach the underlying bone
or even go entirely through a part.

An exception to the usual course of events

Sept. 14-17. 1920

1 84

Rapid Healing of A'-Ray Burn of Third Degree

in a third degree .r-ray burn occurred in a
case which was being treated for a very ex-
tensive blastomycosis of the lower" abdomen.
The patient was a colored male, thirty-
seven vears of age. He was in good physical

Fig. 3.

condition except for an extensive blastomy-
cotic skiij lesion. This lesion was of ten vears'
duration and began as a small "pimple" on
the skin at the perineum. It was of very slow
growth and gradually spread in anterior and
posterior directions, reaching the posterior
limit of the median groove between the nates
but not spreading over the buttocks ; its
greatest spread occurred anteriorly from the
point of origin over the entire scrotum, over
the shaft of the penis, the glans, and it then
invaded the skin over the lower abdomen by
way of both inguinal folds, spreading about
ecjually on both sides of the body to the flanks
at the regions over the iliac crests. (Fig. i. )
In the ten years of growth the patient had
knocked around from doctor to doctor and
clinic to clinic but obtained no permanent re-
lief. The lesion continued to spread slowly in
spite of all efforts to arrest its progress. He
was unable to work and became a public
charge. As is characteristic of this fungus
invasion of the skin, the edges of the lesion
only were the site of the activity; the re-
maining area already run over by the growth

was left a leathery tough hard skin in which
all skin pigment peculiar to the colored race
was lost and he was seemingly turning a
pinkish white. In the zone of activity the le-
sion itself had much of a cauliflower appear-
ance. This zone was from 4 to 5 cm. in width
all along the edge;^ of the involved area.

A'-rav therapy was advised by the late Dr.
Harris ( at that time head of the skin depart-
ment of the Cook County Hospital) and
treatment was begun in September, 191 6. In
view of the marked chronicity of the lesion
and failure of all other therapy to effect a
cure, a more than ordinar\- skin dosage
seemed to be indicated. ^Multiple areas were
necessarv to cover all the lesion present. The
normal skin was protected from the exposure
and three circular areas over lower abdomen
anteric^rlv and one over the perineum were
radiated, four in all, each three inches in
diameter. A formula of 5 milliamperes of
current, a 5 inch spark-gap resistance
(60,000 volts), at a 7 inch target to skin
distance, for five minutes, with 2 milliam-
meters of aluminum filter, was given. No

Fig.

noticeable changes followed the first treat-
ment. A second dose was given ten days later
which was followed in about a week by a
noticeable improvement.

Rapid Healing of A'-Ray Burn of Third Degree

185

Subsequent treatments were given at t^vo
weeks' intervals and the lesion continued lO
improve. After the fifth series the condition
was practically healed with but a few spots
of activity remaining, which required more
treatment. The patient naturally was much
pleased at the outcome and relief from his
condition. He informed me with much joy
that he now, for the first time in ten vears
was able properly to use toilet paper.

davs the entire abdominal wall, the skin, sub-
cutaneous and muscle tissues, in the exact
area treated, about 3 inches in diameter, had
disappeared down to the peritoneum. This
alarming event naturally caused much con-
cern. The coils of the intestines could be seen
through the thin peritoneum which appeared
as a more or less transparent veil. Why this
thin structure did not also break down is not
explained. The patient did not complain of

Fig. 5.

At this time an enforced absence necessi-
tated that the treatments be given by an as-
sistant whose previous work had been satis-
factory. Explicit instructions called for radi-
ating three areas over the abdomen from
right to left and the formula to be followed
exactly as already described. Area No. i was
to be given on the right side anteriorly ; area
No. 2 in the median line anteriorly and No. 3
to be on the left side also anteriorly. Owing
to a slip-up in this proceeding, area No. i was
given which w^as followed by area No. 2.
Then, instead of setting the -I'-ray tube over
area No. 3, the No. i area was given a second
full dose under the impression that this w^as
the area remaining to be treated. Of course
this was not recognized at the time.

In a very short time, the second or third
day following, a complete tissue break down
rapidly developed in area No. i , and in eleven

Fig. 6.

much pain and seemed the least worried of
those concerned. We cautioned all those in
his ward not to startle him or in anv wise
cause any sudden muscular action, for it was
feared that the thin wall remaining might
rupture, through sneezing or other similar
violent movement and thus call for an emer-
gency operation to replace .some popped-out
colon. He was kept very quiet and a sterile
dressing kept in place over the eroded area,
binding it firmly and very tightly over the
hole in the belly wall. We held our breath,
prayed much and feared more, slept but lit-
tle and went about in fear and trembling.
No medication of any kind was given and
plans were made for a later surgical repair,
if possible. (Fig. 2.)

In fifteen days the broken down tissue had
increased but very slightly in extent. (Fig.
3.) During the next few days a surprising

1 86

Hirschsprung's Disease

change took place and in one week one
hardly recognized the area. The edges had
filled in apparently with new regrown tissue,
the hole had closed and its size was now
about one third of the original area. With
wonder we daily observed its progress. We
had of course discontinued all jr-ray treat-
ment to the small, still active spots which
consequently began to spread. In thirty days
(Fig. 4) the burn had made further healing
progress, had become noticeably smaller and
in thirty-nine days (Fig. 5) no definite evi-
dence of the accident was visible. There was
no real scar, and but little puckering or draw-
ing in of the healed-over spot.

The remaining areas of revived blasto-
mycotic growth were subsequently treated
by .r-ray dosage of the same formula as given
above, and a complete cure was obtained.
No untoward sequelae have occurred since
the events here described (three years) and
the patient is now working.

Seeking for an explanation of this unusual
healing of so marked a tissue destruction,
it has been suggested that the area in-
volved was no longer true skin tissue, hav-
ing been changed by the fungus invasion,
and that therefore it responded in a different
way from that in which the normal skin
responds.

HIRSCHSPRUNG'S DISEASE. REPORT OF CASE

By JAMES G. WARE, M.D.
Roentgenologist to the Cottage Hospital

SANTA BARBARA, CALIFORNI.\

TJISTORY.— Miss F. B., age eight, was
-^ ■*- admitted to the hospital with the fol-
lowing history. Father is a syphilitic, and
mother is now in a sanitarium with active
tuberculosis. Patient normal at birth accord-
ing to mother's statement. At the age of
seven months began to have attacks of con-
stipation, which attacks would last for sev-
eral days at a time. Her parents then ob-
served that patient's abdomen had begun to
distend, and for the following three years
had only two stools a week. During one pro-
longed attack of constipation, patient went
into a state of coma, which lasted three days.
During this time she had involuntary lic[uid
stools. Drastic cathartics were administered
and patient regained consciousness. For the
past three years child has been given prune
juice and various fruits in addition to
her regular diet, which has regulated her
bowel action fairly well. Recently, however,
the attacks of constipation have become
more severe, lasting from a week to ten days.
She complains of nausea at times, but does
not vomit. Patient has no desire to play or
exert herself in any way. as it tends to bring
on cardiac distress. She has not lost anv

weight. She appears to be intelligent, and
keeps up well with her schoolmates in her
studies.

Examination. — On routine examination,
child was found to be normal except for the
abdomen. The abdomen was uniformly dis-
tended. A palpable mass could be indistinctly
outlined on the left side. The patient did not
complain of any pain or distress at the time
of examination. She was put to bed and an
attempt made to clean out the intestinal tract.
Quantities of fecal matter were passed fol-
lowing the administration of cathartics and
enemas. On the fourth day the patient was
sent to the ,i"-ray department.

Roentgen Findings. — Screen examination.
Under the fluoroscope the stomach appeared
to be somewhat distended for a child of this
age. Peristalsis was very inactive. No filling
defects were noted. The cap was visualized.
The duodenum appeared to be distended
with gas.

Plate Examination. — Plates made soon
after the ingestion of the meal showed find-
ings similar to those noted above. Six hour
plates showed considerable gastric residue,
only a small portion of the meal having

Hirschsprung's Disease

187

passed into the small intestine, which was
crowded over to the left of the median line.
(Fig. I.) Tw^enty-four hour plates dis-
closed a large residue in the cecum, the as-
cending and transverse portions of the colon

Fig. I. Six-Hour Gastric Residue. Small intestine
crowded over to the left of the median line.

being well outlined. The transverse colon
was deep in the pelvis. Plates made at the
termination of twenty-four hours showed a
small amount of barium in the cecum and
transverse colon. One week later patient was
again fluoroscoped. and a small cecal reten-
tion was observed. She was put to bed and
given daily cathartics and enemas. At the
end of ten days, she was given a barium
enema composed of 1000 c.c. of water, and
180 grams of barium. This was retained
without difficulty. Plates made showed the
sigmoid and descending colon to be greatly
distended, forming a pouch-like mass which
filled the greater part of the pelvis and left
abdomen. (Fig. 2.)

For two days following the administra-
tion of the barium enema, patient passed
quantities of fecal matter and barium. Re-
peated fluoroscopic examinations continued
to show the presence of barium in the cecum,
ascending colon and sigmoid. One week
later the patient was again fluoroscoped

and a small cecal retention was observed.

Diagnosis. — On the roentgen findings and
history of the case a diagnosis of Hirsch-
sprung's disease was made.

Operation and Results. — After three days
of careful preparation, the case was referred
to the service of Dr. Rexwald Brown for
operation. Through a left rectus incision, a
greatly dilated and thickened descending
colon and sigmoid were delivered. Owing to
the fact that the dilatation extended into the
rectum it was found impossible to perform
an end-to-end anastomosis. The distal third
of the descending colon, together with the
sigmoid and proximal end of the rectum, was
resected. This portion of the intestine con-
tained approximately two quarts of liquid
feces. The colon and rectum were closed by
infolding, and a lateral anastomosis made
betw^een the two free ends by means of an
oblong Murphy button.

Fig. 2. Enormously Dilated Rectum, Sigmoid, and
Descending Colon.

The patient's condition following the
operation, and for the first week w^as excel-
lent, and every hope was held for an un-
eventful recovery, but on the ninth day she
suddenly developed an acute peritonitis.
Drainage was of no avail, and the patient
expired.

THE DIAGNOSIS OF A BRAIN TUMOR
BY PNEUMO VENTRICULOGRAPHY

By a. S. MERRILL, ^LD.
Assistant Roentgenologist, Massachusetts General Hospital

BOSTON, MASSACHUSETTS

TN any large clitiic a frequent subject of
-■- consultation between the surgeon and the
• roentgenologist is the cjuestion of the exist-
ence or the location of a brain tumor.

In only a very small percentage of tumors
does the growth cast a shadow on the plate
— Dandy in his studies of the subject savs 6
per cent. These were tun:()rs v.\th definite

adults. In the first case the results were so
striking that it seems worthy of report.

A white boy of six }ears with unimport-
ant previc^us and famih- histories exhibited
symptoms three years ago which were diag-
nosed clinically as probable brain tumor, but
the roentgenograms gave no evidence and
the lesion was never Ic^calized. Subsec[uent

Fig. I. Case I. Before Ixjectiox, showing
Calcified Area.

calcified areas, and naturalh" onlv the calci-
fied portions were visible. ( Jther growths
arising from the intracranial structures, be-
ing of no greater density than the surround-
ing tissues, were of course invisible by the
ordinary methods of examination. The signs
of intracranial tumors so well studied and
ably described by other writers are in manv
cases pathognomonic, but the percentage is
still less than one half and the location of the
lesion is seldom definite.

Inspired by the work of Dandy we have
made an effort in this clinic to follow his
technique in a few cases. Our study has been
limited to three cases, one child and two

Fig. 2. Case I. After Injection, showing
Tumor Surrounding Calcified Area.

course bore out the diagnosis and two years
ago an occipital deciimpression was done
with some temporary relief.

He came to us in an apparently hopeless
condition. Radiograms were made in the
usual positions. The skull was seen to be
unusuall}- large and thin. Mottling of the
inner table and changes in the base suggested
intracranial pressure. The sutures were wide
in the ujjper portion. Just above the mastoid
shadow in the mid-portion of the skull was
seen a calcified area of a horseshoe shape
apparently in the brain.

With the remote hope of locating an oper-
able lesion the surgeons considered ])neumo-

Brain Tumor Diagnosed bv Pneunioventriculography

189

ventriculography. Through a small trephine
opening the anterior horn of the right
ventricle was entered. A large amount of
fiuid was released and air was allowed to en-

Fk;. ,v Case I. Proxe, showing Tumor and
Fluid Level.

ter under atmospheric pressure. Radiograms
were taken in various positions. The tumor

poor condition of the patient it was con-
sidered inoperable.

Following the operation the patient's con-
dition grew worse and on the second day
after he died.

It is the surgical opinion that the sudden
release of so much fluid and great decrease
of intracranial pressure may have hastened
the course, although the patient was prac-
ticalh- in extremis at the time of the
operation.

Although the examination failed to help
this patient or postpone the inevitable, it
demonstrates several valuable points. It
shows that intracranial tumors may be made
visible. It leads us to believe that in similar
cases the examination should be made earlier
before the intracranial changes are so ad-
vanced. It suggests that where much fluid or
great pressure is suspected a measure should
be made as accurately as possible of the
pressure and the amount of fluid withdrawn,

Fig. 4. Case I. Photogkaiji ui Right Hemisphere showing Section ui Tumor.

was distinctly seen surrounding the previ-
ously observed area of calcification and ap-
parently occupying the site of the pineal
body. From its size and location and the

and this restored by an equal amount of gas
under an ecjual pressure.

At autopsy the tumor was demonstrated
identical with the shadow in the plates and

IQO

Brain Tumor Diagnosed by Pneumoventrictilographv

was found to be a teratoma originating ap-
parently in the pineal body, and containing
bone, hair and skin elements. The foramen
of Monroe and the aqueduct of Sylvius were
blocked bv the tumor.

cranial picture. This case complained of
some headache for a few hours, but there
were no disturbing symptoms in either case.
These cases suggest to us that the operation
may be done in selected cases without harm

Figs. 5a and 5b. Case II. Ventricles Practically Normal in Size. Lateral and Third Ventricles

Fairly Well Seen. Possible Mass on Leet.

The other two cases were adults. In
neither^case were the findings conclusive. In
one the Acntricle failed to be injected. In the
other there were suggestions of an abnormal
mass, but we found ourselves handicapped

to the patient. We should make ourselves
familiar with the normal picture by experi-
ments on the cadaver before we can speak
with certainty of small lesions.

The accompanying prints need little

by our unfamiliarity with the normal intra- explanation.

FOREIGN BODY IN THE BRONCHUS FOR FIFTEEN YEARS

By I. SETH HIRSCH, M.D.

NEW YORK CITY

AS illustrative of the relative tolerance
of the bronchi to metallic foreign
bodies, so strikingly in contrast to the almost
immediate reaction which follows the entry
of vegetable foreign bodies, because of the
tendency of the latter to disintegration and
migration (Begin has called this class of
foreign bodies "progressors") the following
case is reported :

practically free of symptoms, with the ex-
ception of a very slight cough. There was no
shortness of breath, no purulent expectora-
tion. Six months ago he coughed up a con-
siderable quantity of bright red blood. After
this he again felt the sensation of something
"moving up and down" in his wind pipe for
two weeks. During this time the coughing
was verv severe and he had considerable ex-

FiGS. I AND 2. Pl. a. No. 220543; Serial No. 70543, July, 1920. Coin (dime) in Left Bronchus.
Destruction and Atelectasis of Left Upper Lobe, Fibrosis and Atelectasis of Left Lower Lobe.

M. G., aged forty-five, entered Bellevue
Hospital because of hemoptysis. The follow-
ing history was obtained: Fifteen years ago
he was holding a dime in his mouth and
someone slapped him on the back and he
felt the coin go down. He thought he swal-
lowed it. He coughed for about ten minutes
after this, trying tc get the foreign body up
but without avail. He was not short of
breath and went about his work as usual,
though for six months following the acci-
dent he could feel something "moving up
and down" in his chest. During this time he
coughed but very slightly. From that time,
however, until six months ago he has been

pectoration with it. The symptoms abated
and he was practically well until two weeks
ago, when severe hemorrhage brought him
to the hospital. From the clinical signs the
diagnosis of fluid at the base of the left lung,
with fibrosis of the upper portion of the left
lung, a possible cavity and a possible aneu-
rysmal dilatation of the aorta was made.
Sputum showed presence of fungus but no
tubercular bacilli.

The radiographic examination shows an
almost complete excavation and atelectasis
of the upper lobe of the left lung, with
fibrosis and atelectasis of the lower lobe. The
heart and mediastinal contents were re-

191

192

Foreign Bodv in the Bronchus

tracted to the left. The trachea, however,
was slightly deviated to the right. The oppo-
site lung showed extensive compensatory
emphysema. Between the seventh and eighth
ribs, posteriorly, just to the left of the me-
dian line, was the shadow of a disc-like
metallic body (the coin), its rounded edges
somewhat roughened (due to calcarious de-
posit). The lateral view of the chest showed
the coin located posteriorly in the main
bronchus of the left lung, and lying in a
plane parallel to the sagittal plane of the
chest. The esophagus was normal.

That metallic foreign substances are tol-
erated in the bronchi without severe symp-
toms is well known in the literature. Such
foreign bodies as nails (Collard), coins
(Mitchel, Baldwin, Dupuytren), pins and
pieces of bone have been found in the
trachea and bronchi, where they had been
for years without giving severe symptoms.
Burch and Lake cite thirty-one cases in
which foreign bodies were present in the
trachea or bronchi in intervals of one year
to sixty, in all of which recovery took place
after expulsion or removal. In a case re-
ported by Dupuytren a ten sol piece re-
mained in the bronchus for ten years.

The pathogenesis of the lung lesion is usu-
ally the following: bronchitis, broncho-
pneumonia (peribronchial infiltration), mul-
tiple abscess formation, coalescence of the
foci with the formation of a large cavity.
With this there is fibrosis both of lung and
pleura. These lesions were present in the case
reported.

The foreign bodies remaining in the
bronchi and trachea for a long time become
covered with calcareous concretion. Several
such cases in which foreign bodies were ex-
pelled after a long period, in calcareous

form, have been collected by Aronssohn. He
cites one case in which a cherry pit in the
right bronchus was expelled a year after its
inhalation, surrounded by a layer of phos-
phate of lime, one inch in thickness.
(Hirsch, Foreign Bodies in the Alimentary
and Respiratory Tracts, Aiii. J. Surg., Janu-
ary and February, 191 3.)

Hemoptysis appears to be a symptom
present in the vast majority of such cases.
Such recurrent hemorrhages may be the only
symptoms for a long period. In many cases,
sometimes in spite of a definite history, it is
usually ascribed t(^ tuberculosis.

It is difficult to understand how, in these
days of abundant roentgen examinations,
any foreign body in the respiratory tract can
He undiscovered for any length of time. The
paucity of symptoms in a certain class of
cases, of which the case reported is an ex-
ample, may perhaps account for this. But
nevertheless cases are being continually en-
countered in which, in spite of a character-
istic history and distinct symptoms, the for-
eign body has been permitted to remain in the
respiratory tract until irretrievable damage
has been done to the lung and the removal
of the foreign body,- even by the skillful
bronchoscopist, is no longer a simple matter.

The almost uncanny dexterity with which
men like Chevalier Jackson remove the of-
fending bodies from the inner and most sub-
merged provinces of the lung makes one feel
that the life of Pope x\drian IV, who died of
a fly in his bronchus, would have been saved
if Jackson had lived in Rome in the days of
that august personality.

During the removal of the foreign body
(a ten cent piece, partially encrusted) in the
case reported, severe hemorrhages occurred,
from which the patient died.

X-RAY FINDINGS IN THE CHRONIC GAS CASES == t

By HKNRY C. PILLSBURY, M.D.

VVASHIXGTON, D. C.

THE close of the war and the return of .
our troops from France find scat-
tered throughout the country nian\- men who
have been subjected to the action of irritant
gas at some time during their service. These
men will soon return to their civil status, and
from time to time will appear at the .r-ray
clinics for the diagnosis of lung conditions.
It is confidently expected that no man will be
discharged, and later leave the care of the
Public Health Service, who stands in need
of any further medical treatment for the
condition that was caused by his service ; but
these "gassed cases" will carry with them
for a long time the scars caused b}- the irri-
tant effect of the gas. Unless pathology of
this condition is thoroughly understood, er-
roneous diagnoses may be made, and undue
importance may be attached to the various
thickenings of the bronchi seen.

Especially must the clinician l)e on his
guard against the diagnosis of tuberculosis
in these cases. It is not considered likely that
any roentgenologist would make this mis-
take, as the appearance of the plate is en-
tirely different in the two cases.

The gases that leave behind them a
chronic change in the lungs are chlorine,
chloropicrine. and especially phosgene. Con-
trary to the usually accepted opinion, mus-
tard gas is practically without effect on the
lungs. In this connection, care must be taken
with the history. Nearly always the patient
will state that he was gassed b)- mustard,
when in point of fact he had no idea what-
ever with what gas he was affected. The sev-
eral gases were used together to a certain
extent. Further mustard causes such severe
external burns that its action is most im-
pressive. It is an easy name to remember,
and in a great majority of cases soldiers

will give the history of gassing by mustard
quite confidently, although they may have
actually inhaled phosgene.

The Research Division of the Chemical
Warfare Service has done invaluable work
on the pathology caused by the different
gases. The descrij^tion given below is taken
almost entirely from their monographs. It is
regretted that the masterly and scientific de-
scri[Jtions sht)uld be so garbled as has been
inevitably the case, in the effort to present
die condition as briefly as is consistent with
reasonable clearness.

The pathology in the lungs caused by
these gases is similar, but presents certain
points of difference. Chlorine damages es-
pecially the upper respiratory tract, the
trachea and die larger bronchi. This gas is a
powerful irritant, and strikes that portion
of the lung with which it first comes in con-
tact. There is rapid and complete coagula-
tion of the mucous surface; later, after re-
cover^■, the epithelium is restored, and the
trachea returns to normal, except for the
deposition of scar tissue. Rarely the injury
mav extend to the distal alveoli, causing des-
quamation of the alveolar epithelium and fo-
cal areas of necrosis.

Chloropicrine injures the epithelium of
the trachea and larger bronchi, as does chlor-
ine, but to a lesser degree. With this gas, the
most notable effect is seen on the medium
and smaller sized bronchi. When the bron-
chiolar wall has been seriously damaged, an
active proliferation of fibroblasts occurs, and
the bronchial cavity becomes filled wifli
granulation tissue; the final result is an
obliterative bronchiolitis, with its consequent
atelectasis or localized emphysema. The
same result may also occur as a consequence
of occlusion of the smaller bronchi by in-

"Puhlished with permission of the Surgeon General, V. S. Army, who is not responsible for any opinion expressed or conclusions

reached herein. Bcar-l of Publications, Mary Pearson McKnight, Contract Surgeon, U. S. A, Secretary.

jThesis presented on application for membership in The Americ.\n Roentgen R.^y Society.

193

194

A'-Ray Findinfrs in the Chronic Gas Cases

flammatory exudate, or by masses of necrotic
cells. There is regeneration of the epithelium
of the bronchi and alveoli, and organization
of the necrotic bronchiolar wall, with scar
formation. Focal atelectasis and emphysema-
tous patches may remain.

Phosgene, the most important of all the
gases used, in so far as the effect on the
lungs is concerned, acts chiefly on the lining
epithelium of the smaller bronchi and bron-
chioles. The upper respiratory air passages
escape almost entirely. This gas as it is in-
haled has no irritant properties. When, how-
ever, the gas reaches the moisture-laden
smaller air passages, it is broken up, and
HCl evolved. The lining epithelium is de-
stroyed; later the epithelium regenerates,
but there is a growth of granulation tissue
in the walls of the finer bronchi which causes
a thickening of its wall and a periljronchitis.
In fact, the outstanding features of the later
stages of this condition are the thickening of
the walls of the bronchi, and the peri-bron-
chitis. In a certain number of cases this
process goes further, and we find that the
infiltration of the walls has extended to the
point that the bronchus is entirely occluded.
When this occurs, localized atelectasis and
restricted areas of emphysema mav 1)e ex-
pected to be found.

Summarizing the action of the three most
important gases, we find, therefore, that
chlorine, the most irritant, affects the lining
epithelium of the parts with which it first
comes in contact — the trachea and larger
bronchi. Chloropicrin. which must be broken
up into a residue and HCl, only becomes ef-
fective after it has reached a part of the lung
where moisture can be found — the medium
sized and smaller bronchi. Here it causes the
same lesions as chlorine. Phosgene is a little
more stable than chloropicrin, and is only
broken up into HCl and its residue in the
smaller bronchioles and alveoli. It is here
that it has its effect. It need not be supposed
that these three gases are strictly limited in
their action to the parts of the lung de-
scribed ; a massive dose or prolonged expo-
sure of phosgene or chloropicrine will affect
the larger bronchi as well as the finer ones.

The history is usually indefinite. As a rule
these patients entirely recover their strength
and their ability to do work. Occasionally,
in the more severe cases, there may be short-
ness of breath on exertion. Nearly always
they report to the roentgenologist for exam-
ination because of abnormal auscultatory
signs picked up by the clinician when con-
sulted for some intercurrent disease.

The .f-ray plate will show changes closely
resembling those found in pneumoconiosis.
Adopting the classification used by Pancoast,
Miller and Landis in their article published
in The American Journal of Roentgen-
ology, March, 1918, we find that these cases
of gassing simulate the condition described
by these authors as Group i, the stage of ir-
ritation. As in the lungs irritated by the in-
halation of dust, we find that the bronchial
markings are unusually prominent. Reaching
out from the hilus like a bush in the winter
time the thickened stalks and twigs of the
bronchi extend to the mid-portion of the
lung, standing out clear and distinct, with no
splotches of exudate to mar or confuse the
picture. The bush is symmetrical ; it is not
confined to one lobe, or to the upper more
than the lower portion. It reaches out from
the hilus evenly, into all lobes, and is pres-
ent on both sides. As a rule, the extension is
more into the middle lobe on the right side,
and into the lower portion of the upper lobe
on the left. Because of the overlying heart
shadow, the involvemeilt on the right is
more apparent than it is on the left. In some
instances, added to the outermost twigs, are
finer linear markings reaching to the peri-
phery. In the more severe cases, there may
be an area or two of localized atelectasis.

Should the gas be chlorine, or should the
exposure to chloropicrine or phosgene be un-
duly prolonged, then the picture is varied by
lesions of the trachea and largest bronchi.
This condition is differentiated from the
early cases of pneumoconiosis in two par-
ticulars. The hilus shadow may not be en-
larged ; its enlargement when present is
caused by the chronic bronchitis that some-
times persists. In the second place, there are
no small areas of increased density to give

Practical Application of Sphere Gap to Roentgenotherapy

195

the characteristic mottled appearance of dust
inhalation.

The diagnosis from pulmonary tuberculo-
sis is ordinarily not difficult. The distribu-
tion, the uniformity, and the absence of
areas of consolidation, suffice to make the
distinction clear. In certain instances, how-

ever, the presence of areas of atelectasis or
emphysema, particularly when these occur in
the upper lobes, may confuse the diagnosis
considerably. Given the history of gassing, a
consideration of the pathology that may en-
sue will assist in making the interpretation
less difficult.

THE PRACTICAL APPLICATION OF THE SPHERE
GAP TO ROENTGENOTHERAPY*

By H. J. ULLMANN, M.D.

Roentgenologist St. Joseph's and Children's Memorial Hospitals, Chicago

CHICAGO, ILLINOIS

T N looking through the literature on roent-
'- genotherapy one cannot help noticing the
great variation in spark gap used by different
workers in obtaining essentially the same re-
sults. It would seem, according to later
writers, that such variations should produce
results varying proportionally to the differ-
ences in gaps used and that, with the same
gap, distance, milliamperage and time, es-
sentially equal effects should be obtained, if
Coolidge tubes be used. It is well known,
however, that this does not occur in practice.
What is an erythema dose with one machine
is not necessarily the same with another. If
we use the same voltage, distance, intensity
and time we would expect to get approxi-
mately the same effects with transformers of
similar type, but the difficulties of working
out dosage when changing from one machine
to another or when trying to duplicate an-
other worker's results with a given dosage
are very real.

Why is one not able, with accurate meters
and the Coolidge tube, to obtain as uniform
results from a given dosage as with the
alkaloidal drugs given hypodermatically ?
There one expects uniform results in the
same type of patient whether a record or a
Luer syringe is used provided the same
quantity and quality of the drug is used.

In measuring dosage of the roentgen ray
we have the same two factors, quantity

*Read at the Midwinter Meeting, Central Section ol

Feb. .

(represented by milliamperage, time and dis-
tance) and quality, depending upon voltage
applied to the tube terminals. Wave shape,
number of cycles, etc., are not taken into
consideration, as there is little evidence at
present showing their importance in roent-
genotherapy. There is no question but that
we get sufficiently accurate quantitative
measurements, with the milliammeter, a
clock and a tape measure; but what about
the qualitative?

The usual method of measuring voltage is
in terms of spark-gap between blunt points,
sometimes in kilovolts as read on a meter in
the primary circuit; and as these seemed
much like using an elastic tape measure to
measure distance the following investigation
was undertaken to determine how great the
inaccuracy of the orthodox method of meas-
uring voltage (penetration) was. Before tak-
ing up the results of actual measurements
made at the tube the drawbacks of the needle
gap and voltmeter on primary will be brieflly
taken up.

In measuring voltage with a needle gap
considerable inconsistency has been found by
investigators, and this seems especially true
of European workers. Quoting J. Lustgar-
ten *: "Those that have worked with the gap
specified (standard A. I. E. E. needle gap)
know that it is difficult to check the Ameri-
can values and even to repeat their own re-

The American Roentgen Ray Society, St. Louis, Mo.,
:i, 22, 1921.

196

Practical Application of Sphere Gap to Roentgenotherapy

suits on successive days. One reason for this
lies in the effects on the brush discharge of
humidity, pressure and temperature, position
of the needles with respect to the supports
and neighboring objects and the local condi-
tions in the circuit. The brush discharge in
the case of needle points always precedes the
spark (except at very small distances). A
screening by metallic discs at the back of the
needles will not prevent humidity, pressure
and temperature destroving the standard

gap."

To realize this inconsistency one has only
to turn to the tables derived by different in-
vestigators showing the relation between dis-
tance of separation and the breakdown volt-
age. For example :

U. S. Army X-Ray IManual:

40 KV Gap 3 inches

50 KV Gap 4 inches

etc., the ration being 10 KV per inch plus 10.
Peek, Dielectric Phenomena in High Volt-
age Engineering, first edition:

40 KV Gap 2 13/32 inches
50 KV Gap 3 3/17 inches
etc.

Raper, Dental Radiography, first edition:

10 KV" per inch.
Knox, third edition, p. 19. Type of gap
not stated:

no KV 4 inches

150 KV 8 inches

190 KV 12 inches

230 KV 16 inches.

This table obviously refers to a sphere gap
and shows the difficulty one would have in
attempting to correlate his work with the
English standards.

The needle gap is also cumbersome if one
attempts to use it accurately. Section 245
A. I. E. E. Standardization Rules specifies
the following:

"The sparking points should consist of
new sewing needles supported axially at the
ends of linear conductors which are at least
twice the length of the gap. There should be
no extraneous body near the gap within a
radius of twice its length."

How many roentgen plants are equipped

with a gap built according to the above?
The average gap as commonly used brings in
many sources of error not found in the
standard. Peek - makes the following state-
ment:

"The needle gap is unreliable at high volt-
ages because, due to the brush discharge and
broken-down air that precedes the spark-
over, variations are caused by humidity,
oscillations, and frequency.

"The needle gap is also inconvenient be-
cause needles must be replaced after each
discharge; the spacing becomes very large
at high voltages, and the calibration varies
somewhat with the sharpness of the needle."

"A higher voltage is required to spark
over a given needle gap when the humidity
is high than when it is low.

"All spark gap curves of whatever form of
gap must be corrected for air density — that
is, altitude and temperature. For low volt-
tages the spark-over of the needle gap de-
creases approximately as the air density. At
higher voltages the effect becomes more
erratic, probably due to humidity."

In using a KV meter on the primary even
greater sources of error may be encountered.
To quote Chubb and Fortescue ^ :

"The most usual method of measuring the
high tension voltage is to measure the pri-
mary potential and multiply by the ratio of
the transformer. Voltages obtained by this
method are generally very much in error due
to the distributed capacity in the high tension
winding of the transformer, harmonic dis-
tortion of the applied voltage wave and the
capacity of the terminal bushings and the
apparatus to which the high voltage winding
is connected. The effective low tension volt-
age is usually indicated so that there is no
measure of the maximum unless a pure sine
wave of voltage is applied, there are no ap-
preciable distortions due to the harmonic
components of the exciting currents and the
capacity regulation can be corrected."

If the usual methods of measuring voltage
(penetration) are so faulty, what is the rem-
edy ? Engineers have been using a sphere gap
for a number of years to measure high volt-
ages and it is well known to be the most

ERRATA

The following corrections were received from Dr.
Ullmann after the article had been printed:

p. 197: Ingenieurmessen should be Ingenieurwesen

p. 198: first column: MacKee formula should read:

gap X time X miUiamperes ^ ,,

~- "^ =36/64

distance

p. 198: second column, table:

In caption, V and V should be U^ and U'

Third line, last column, — no should

be — II.

"\^ hn - [;rnrf:>

ffff-";:'

-:r''o'yi:.ii\ :^.Ql .q

Practical Application of Sphere Gap to Roentgenotherapy

197

accurate practical method. It is more con-
sistent, the breakdown voltage being affected
only to a negligible degree by widely varying
conditions of atmospheric pressure, humid-
ity, proximity of neighboring bodies, etc. ;
more convenient because the terminals do
not have to be renewed and it requires less
space.* Under certain conditions the break-
down of the air gap between equal spheres
is very constant and the sphere gap that has
already been suggested as a standard for
high voltage measurements has been found
to be more reliable than the usual methods of
test.^ The results of many tests show the
breakdown voltage to be independent of
wave shape and frequency when expressed
in terms of the maximum value of the volt-
age wave.^ Farnsworth ^ quotes Weicher's
Mitteilungen iiher Forsclmngsarbeiten auf
dem Gchiete der Ingenteurmessen, Berlin,
1911:

"For sphere gap used over a separation
not greater than the diameter of the spheres
the influence of the factors of humidity, tem-
perature, pressure, frequency and electrical
capacity on the sparking voltage is as
follows :

"Humidity — No effect.

"Temperature — Sparking voltage is in-
versely proportional to the absolute tempera-
ture.

"Pressure — Sparking voltage is directly
proportional to the barometric pressure.

"Frequency — Within commercial range —
20 to 75 cycles^ — frequency has no effect on
the sparking voltage.

"Electrical capacity — No influence."

If the sphere gap is so accurate it should
prove any variation of voltage measurements
made in estimating .ir-ray dosage. In order
to test this the following procedure was car-
ried out in a number of hospitals and private
laboratories at Chicago.

The roentgenologist was requested to set
his machine for a definite voltage and milli-
amperage such as he used in therapy and
then the voltage was measured at the tube
terminals with a sphere gap. Only Coolidge
tubes were tested. The findings are as fol-
lows:

MACHINE A

Meter

reading

Milli-
amperes

Rheo
Button

Auto
Button

Gap in
inches

S.G.
KV

30 25

35 ••••• 25

40 25

45 25

50 25

55 25

60 25

65 25

70 25

75 25

80 25

76 5

85 5

• 35
. 40

• 45

• 50
55

■ 59

■ 64
. 69

74
. 79
.113
,102

7H
8

87/^

5/2

34-5

MACHINE B

'Meter
reading
KV

Milli-
amperes

Rheo
Biitton

Auto
Button

Gap in
inches

S.G.

35 •••

.. 25

46 ...

.. 25

57^/4..

.. 25

47 ...

.. 5

58 ...

.. 5

6214..

•• 5

63 ...

. . 2

70 ...

.. 5

72, ■■■

.. 5

76 ...

•• 5

78 ...

.. 5

7
7
5

10
12

45^

5Y2

7/2

46
56
70
58
70
65
62
62
65
73
80

MACHINE C
No auto transformer

Gap in inches

Millianiperes
High Button

S. G. KV

4^.
5 •

5 .

6 .

7 .

27 ....

5 ....

..... 5 ....

5 •••.

5 ....

Low Button

5 ..-.

5 ...•

5 ....

5 ••••

52
60

51
60
68

60
70
80
90

MACHINE D

No a^ito

Gap in inches

Millianiperes

S. G. KV

54
55
70
73
75
82

198

Practical Application of Sphere Gap to Roentgenotherapy

MACHINE E
No auto

Gap in inches

Milliamperes

S. G. KV

7J^ to8 5

MACHINE F
Auto transformer

Gap in inches Milliamperes S. G. KV

6 2 65

6 6 65

8^ 5 82

It is easily seen from an examination of
the above that there is considerable variation
of voltage where one would expect uniform-
ity from the results of his spark gap read-
ings.

In order to get these findings in terms of
dosage the following table was made. Col-
umn C is the gap between points in inches as
measured by the operator. KV is the actual
voltage at the tube as measured by the sphere
gap. U^ is an arbitrary unit based on the
MacKee formula —
distance^

gap X time X milliamperes ^"' ' "^
one uqit, and represents what the operator
thought he was using. U^ is derived in the
same way, using 70 KV instead of a 6 inch
gap, and represents what he actually got.
70 KV was taken because it more nearly rep-
resents the actual voltage at the tube when
the point gap registers 6 inches.

Per cent plus or minus represents the dif-
ference between what the operator thought
he was using and what was actually used.

Per

t/i

cent

Machine A

sYa ■

. . 71 ••

. .96 ..

. I.OI .

■ +4

Machine B,

setting I

6 .

.. 65 ..

. I.OO .

• -93 .

• • —7

Machine B,

setting 2

6 .

.. 70 ..

. I.OO .

. . 100

Machine C

6 .

.. 60 ..

. I.OO .

. .85 .

..—15

Machine D

6 .

.. 55 ••

. I.OO .

. .80 .

. . ^20

Machine F

. . 65 . .

. I.OO .

• -93 •

..— 7

the habit of using for an erythema dose he
would actually give 30% more. Conversely
if operator of A transferred to D and gave
what he supposed would be an erythema dose
he would actually be using only yy% of the
amount.

From the above table it is readily seen that
if an operator using machine D should
change to A and give what he had been in

Per
cent

Machine A

8 .

.. 93 •.

. I.OO ..

. 1.03 .

. +3

Machine B

.. 80 ..

. I.OO . .

. .89 .

. —II

Machine C,

setting I

.. 80 .

. I.OO . .

. .89 .

.. — no

Machine C,

setting 2

.. 74 •

. I.OO . .

. .82 .

..—18

Machine D,

setting I

.. 73 •

. I.OO .

. .81 .

. . —19

Machine D,

setting 2

... 70 .

. I.OO .

. .78 .

. . —22

Machine E

.. 75 •

. I.OO ..

• .83 .

..—17

In this table 90 KV was taken as repre-
senting 8 inches of back-up and an 8 inch
gap the unit for deep therapy.

From the above it can be seen that if what
would be an erythema dose on machine D,
setting 2, was given with machine A, the
patient would receive 1.32 times the dose,
while if the readings used on A in produ-
cing an erythema were used on D only 76
per cent of the dose would be received.

If dosage were based on kilovolts instead
of spark-gap and machines were calibrated
so that one knew that certain settings would
produce a definite voltage one should be able
to change from one machine to another and
expect to get the same results without pre-
viously testing out the effects on a patient.
Also, a roentgenologist could publish the re-
sults obtained from a certain dosage with the
knowledge that those who attempted to dup-
licate his results would at least use the same
quantity and quality of rays.

There is nothing difficult in using a sphere
gap. In fact it is easier as there is no corona
and no preliminary sparking. It either fires
or it does not, and the difference of a small
fraction of a millimeter determines the
sparking point. It is easily calibrated to read
directly in kilovolts, and the machine once
calibrated for the settings in common use, it
will only be necessary to recalibrate at long

The Value of Prophylactic Z-Ray Treatments

199

intervals or when tubes are changed or dif-
ferent control buttons used.

CONCLUSIONS

The present method of estimating quality
or penetration by parallel spark-gap between
blunt points is exceedingly and unnecessarily
inaccurate and is equivalent to measuring
tube distance with a rubber band for a tape
measure.

The use of the sphere gap in estimating
voltage between tube terminals is accurate
enough for all practical purposes and is ac-
tually easier to use than blunt points due to
absence of brush discharge.

If the number of kilovolts used were
stated instead of the amount of spark-gap
back-up in reporting dosage the results could
be duplicated by other workers as easily as
in giving drugs hypodermatically and would
be an advance in dosage standardization.

I wish to thank Dr. W. D. Coolidge for
his advice and assistance in this work.

REFERENCES

1. LuSTGARTEN, J. J. Inst. Ehc. Engineers, July, 1912.

2. Peek, F. W., Jr. Dielectric phenomena in high

voltage engineering.

3. Chxjbb and Fortescue. a. I. E. E., Feb., 1913.

4. Farnsworth and Fortescue. A. I.E. E., Feb, 1913.

5. Farnsworth. A. I. E. E., Nov., 1913, p. 2089.

THE VALUE OF PROPHYLACTIC X-RAY TREATMENTS*

By SAMUEL STERN, M.D.

Radiotherapist to Alount Sinai Hospital and Chief of the Radiotherapy' Department of the

Mount Sinai Dispensary

NEW YORK CITY

TT is rather difficult to determine the value
"*- of treatments intended to prevent the
recurrence of ailments presumably cured.
Nevertheless there are certain indications
that justify our drawing definite conclusions
as to the results accomplished by the aid of
these treatments.

If we know through long experience that
in a series of similar cases we may expect a
certain number of recurrences, and then find
that as the result of treatments carried out
this number has been diminished, we are
justified in presuming that our treatments
have been of some value.

Conclusions reached upon these premises
are always open to the objection that perhaps
the series of cases, while apparently similar,
have in reality not been quite the same.
Every surgeon has his own statistics as to his
percentage of recurrences in malignant cases
operated by him, and they vary in a large
degree. Another, and in my opinion, more
convincing method of reaching conclusions
as to the value of prophylactic treatments, is
to take selected individual cases of a charac-

•Read at the Twenty-first Annual Meeting of The .American

ter which in the opinion of the operating sur-
geon would unquestionably result in the re-
currence of the lesion operated for. If in
these cases we succeed through our treat-
ments in preventing this expected recurrence,
we are in a much better position to show
concrete proof of the value of the treatments
carried out.

The object of this paper is to describe a
number of cases which without some inter-
ference would have unquestionably resulted
in a recurrence, and to show that by a series
of prophylactic .r-ray treatments this ex-
pected recurrence has never materialized.

Case I. Mrs. F. S., sixty-two years old.
referred to me by Dr. H. Herman in
October, 191 1. with a diagnosis of papilloma
of the tongue.

Patient had a small growth, about the size
of a lima bean, on the edge of the right side,
at about the junction of the second and last
third of the tongue. There was something
suspicious about the appearance of the lesion,
and I reported to Dr. Herman that in my

Roentgen Ray Society, Minneapolis, Minn., Sept. 14-17, 1920.

2()0

The Value of Prophylactic A'-Ray Treatments

opinion we were dealing with an epithelioma
and not a papilloma. We decided to remove
a small section for microscopical examina-
tion, this to be followed by immediate
fulguration.

The examination was made by Dr. Har-
low Brooks and the lesion was found to be
an epithelioma. The fulguration (not dessi-
cation) was followed by periodical prophy-
lactic A'-ray treatments, with the result that
up to date (nine years later) there is not the
slightest sign of recurrence and the patient is
apparently perfectly well.

The patient was treated with a unipolar
^--ray tube which I devised in 1904.^ This
tube enables us to apply the x-x^y in imme-
diate contact with the part to be treated.
While the output of this tube is rather small,
the fact that it can be put in direct contact
with the tissues makes it possible to admin-
ister considerable .t'-ray at each treatment.

Case II. Miss A. B., forty-seven years old,
referred to me by Dr. D. D. Goldstein in
November, 191 3. Mother died of cancer of
breast in 1908. Patient first called on Dr.
Goldstein in November, 191 3. He found that
she had a fair-sized tumor in the right
breast, with axillary involvement. He ad-
vised immediate operation, but patient waited
about two weeks, at the end of which time
there was a very marked increase in the size
of the tumor.

On operation there was found to be a large
tumor of a very diffuse type, with marked
involvement of the axillary glands. The
sheets of all the blood vessels were involved
and they all had to be stripped. The micro-
scopical examination showed the tumor to be
a medullary carcinoma of a very malignant
type.

The patient followed up her jr-ray treat-
ments in a very reluctant way. She felt that
she was wasting her time and money, so I
had to be satisfied with treating the operated
side where recurrence seemed most immin-
ent. I succeeded in holding her for about one
year, after which time she disappeared. I
next saw her in July, 191 9 (about six years

1 Medical Record, Sept. 24, 1904.

after her treatment). The right side, where
she had the prophylactic treatments, has re-
mained entirely free ; but the left side became
involved and was operated on by Dr. D. A.
Moschkowitz, who found a very malignant
diffuse type of carcinoma with marked axil-
lary involvement. I began to treat this side
and up to date she has remained free of any
recurrence.

I consider this a most instructive case.
The original side (right) which was almost
entirely involved in a very malignant type of
extremely diffuse carcinoma, has remained
free up to date (six years) following the
prophylactic .r-ray treatment, while the oppo-
site side, which did not receive any treat-
ments, was the site of recurrence.

Case III. Mr. L. M. E., sixty years old,
referred to me by Dr. Edwin Beer in Janu-
ary, 191 6, for prophylactic .r-ray treatments
following a nephrectomy for hypernephroma
of the left kidney. I will give Dr. Beer's
description of this case, as published by him
in the International Journal of Surgery, De-
cember, 1 91 9:

"Mr. E., aged sixty odd years, was oper-
ated by the lumbar route for an acute hema-
turia from the left kidney. The diagnosis of
hypernephroma of the left kidney had been
made and the tumor mass could be felt in
the left lumbar region. If ever a patient
looked absolutely hopeless to the surgeon this
patient surely did. The pelvis of the left kid-
ney was filled with the tumor mass, which
extended through the parenchyma and then
had grown through the capsule of the kidney
into the perinephritic fat, where a tumor as
large as a good-sized fist was growing. The
kidney was removed through the lumbar
route, but naturally, with the tumor extend-
ing from the cortex, it seemed at the time
that it would be impossible to deliver the
kidney and tumor without spilling the tumor
cells." (As a matter of fact, in a letter writ-
ten to me by Dr. Beer on July 6. 1920. he
states that he thought he must have spilled
some of the viable tumor tissue.) "After re-
moval of the kidney, all perinephritic fat
was carefully excised, and the patient was

The Value of Prophylactic X-Ray Treatments

20 1

subjected to intensive jr-ray therapy. To-
night (four years after operation) the pa-
tient presents himself in perfect health ap-
parently. Last spring I made a complete
examination and found no evidence of any
disease."

Unfortunately I heard recently that this
patient had passed away, suffering from a
brain lesion, perhaps due to some metastasis
in the brain. This I could not make sure of.

Case IV. Mr. L., forty-five years of age,
referred to me by Dr. A. Hyman, in August,
1916, for prophylactic treatment, following
an operation for carcinoma of the testicle.
I will quote from Dr. Hyman's letter to me
(June 7, 1920) in reference to the case:

"Mr. L. was operated on July 19, 1916.
In incising through the skin of the scrotum,
a large amount of pus with necrotic material
was evacuated; all the scrotal layers were
edematous. A large tumor of the testicle was
found, which had broken through the tunica
and had infiltrated the scrotum. The tumor
was necrotic in areas and the size of a fist.
A typical orchidectomy was done, removing
the cord up to the external ring. Pathological
report; Carcinoma. In view of the fact that
the growth had ruptured through the tunica
and had become attached to and had infil-
trated the scrotal tissues, I considered the
prognosis very bad, and advised either .r-ray
or radium treatment. It is now almost four
years since his operation and .r-ray therapy ;
the patient, when last examined three months
ago, was in excellent condition, with no evi-
dences of local recurrence or metastases. A
statement from his family physician, re-
ceived a few days ago, confirms this report."

This patient, when first seen by me, had a
great deal of induration in the operated re-
gion— so much so that I even feared at the
time that a local recurrence was imminent.
He also had considerable induration in the
inguinal region, and Dr. Hyman felt quite
confident that unless some method was
found to prevent it a local recurrence was
unavoidable.

Case V. Mrs. L., fifty-three years old, op-

erated on April 14, 191 6, by Dr. Cragin for
double cystic ovaries. On section, both cysts
showed a cystic and a firmer solid new
growth, with part of the capsule invaded by
tumor tissue. At the time of the operation,
one of the cysts ruptured and the contents
spilled into the peritoneum. On microscopical
examination, the solid portion showed nests
of large cells and a well-marked alveolar ar-
rangement. A diagnosis of adeno-carcinoma
was made. This condition was unsuspected
before and even during the operation, so the
operation was not as thorough and radical
as it would have been had the condition been
recognized. As part of the capsule was in-
volved and the contents of the cyst spilled
into the peritoneum, recurrence was much to
be feared.

Prophylactic .r-ray treatments were car-
ried out for about a year and a half, and
there has been no sign of recurrence up to
date (four and a half years after operation).

About two months ago this patient was
operated upon for a gangrenous appendix.
At this time the surgeon carefully explored
the pelvic organs and found the uterus freely
movable, without the slightest sign of re-
currence. She made an uneventful recovery.

I have treated a number of other cases that
I think would also clearly demonstrate the
value of prophylactic .r-ray treatments, but
my time does not permit me to go into detail
about these, as I would like to say a few
words in regard to the technique and dosage
that I have been using.

Prophylactic .r-ray treatments, to be of
value, must be efficient and must be persisted
in for a considerable period. If possible, they
should be kept up for about three years after
the operation. This is very difficult. Most of
the patients will be tired of the treatments
long before this period expires, and it can
only be carried out if you have an intelligent
patient to deal with and if there is a proper
cooperation with the operating surgeon and
the family physician.

I try to give the treatments in the follow-
ing routine where I can: First treatment, as
shortly after operation as possible ; the next

202

The Value of Prophylactic X-Ray Treatments

two treatments, at about three weeks' inter-
vals; the next two at four weeks' intervals.
This is followed by treatment at six weeks'
intervals for the balance of the first year.
The second year treatments are given at two
months' intervals, and the third year, at
three months' intervals.

Of course, the treatments given the first
year are the most important, and in the ma-
jority of cases you will find considerable
difficulty in holding your patients longer than
this ; but whenever possible, try to get them
to persist the full time.

In treating them, be sure to take in as
large an area as possible, with special atten-
tion to the glandular region surrounding the
involved area, also the parts where experi-
ence has taught us to expect most probably
a metastasis. For instance, in carcinoma of
the breast the opposite side should get some
treatments — not necessarily as many as the
involved side ; and, in addition, I think it is
advisable to treat the lumbar spine, where
many of the metastases will appear.

I think the time will come when these pa-
tients will be given a complete .^--ray bath —
in fact, I believe it is quite feasible now.
Instead of using small fields, we can have
our tube at a distance of about i6 or even
20 inches, take in large areas at a time, and
expose the entire body from all directions.
I have not tried this as yet, but I am seriously
thinking of doing so.

The cases reported above were all treated
with the small field cross-fire method.

Dosage. — Try never to produce an ery-
thema in these cases. It unnecessarily fright-
ens the patients, discourages them from per-
sisting with the treatment, and leads to telan-
giectases and other unpleasant skin condi-
tions. I never use more than three- fourths of
my maximum dose at any exposure. I find
it more satisfactory to speak of maximum
dose, and fractions thereof, than of a definite

number of X. Your maximum dose never
varies, while the measurements in figures of
X generally do.

In standardizing my apparatus I find that
the following figures represent my epilating
dose — that is, a dose which will produce epi-
lation without an erythema. I have taken this
as a standard maximum dose, above which
I never go.

Apparatus. — Forty centimeter air-cooled
coil, with gas and mercury jet interruptor.

Coolidge tube.

Distance Spark-gap Ma. Time

Filter

8 Inches 9 inches

10 4 mm. aluminum
and several lay-
ers of photo-
graphic paper.

In giving these treatments, I use the above
formula, except that the time is seven and a
half minutes instead of ten. The tendency
has been recently to abandon the aluminum
filters for those made of copper and zinc.
These metals have the advantage of increas-
ing the -f-ra}' penetration, but have the dis-
advantage of reciuiring much longer expos-
ures. Where you have a large area to cover,
this time element becomes of great import-
ance, especially in patients who do not stand
the treatments well and who are subject to
various kinds of constitutional disturbances.
Still, I think that probably we shall have to
make the best of this disadvantage. If there
is any additional therapeutic value in higher
penetrating rays, these patients ought to get
the benefit of it.

In closing, I wish to say that I firmly be-
lieve sufficient evidence has been gathered
by this time to justify our belief in the value
of prophylactic .r-ray treatments. Every
operation for malignancy should be fol-
lowed up with these treatments, and these
patients given the additional chance to escape
recurrence.

THE AMERICAN JOURNAL OF ROENTGENOLOGY

H. M. Imboden, M. D., Editor " Paul B. Hoeber, Publisher

Issued Monthly. Subscription, $6.co per year. Advertising rates submitted on application. Editorial office.
480 Par\ Avenue, T^ew Tor}{. Office of publication, 67-69 East 59th Street, J'iew Tor\.

Information of interest to all readers and lists of officers of The American Roentgen Ray Society and
The American Radium Society will be found on the two pages preceding Table of Contents.

TWENTY-SECOND ANNUAL MEETING THE AMERICAN ROENTGEN RAY SOCIETY

WASHINGTON, D.C., SEPTEMBER 27, 28, 29, JO, I92I

Headquarters, Meetings and Exhibits: Hotel 'Washington. Hotels: Hotel "Washington and The T^ew Ebbitt.
SIXTH ANNUAL MEETING THE AMERICAN RADIUM SOCIETY

BOSTON, JUNE 6 AND 7, 192I. HEADQUARTERS, HOTEL BRUNSWICK

WASHINGTON MEETING

PRELIMINARY ANNOUNCEMENTS

A. C. Christie.

The Twenty-second Annual Meeting of
The American Roentgen Ray Society
will be held in Washington, September 27,

28, 29 and 30, 1 92 1. Headquarters, meetings
and exhibits will be at the Hotel Washington,
Pennsylvania Avenue, opposite the Treasury.

The hotel rates are as follows :

Hotel Washington, every room having
private bath with shower, tub and running
ice water (European plan only) :

Single rooms

Double rooms (double bed)

Double rooms (twin beds)

Per day
$5.00 to $7.00
8.00
10.00 to 12.00

The New Ebbitt (European plan only) :

Per day
Single room without bath $2.50

Single room with bath 4.00

Double room without bath, each person $2.50
Double room with bath, each person, 3.50

Also a number of large suites, both with
and without bath, which will comfortably
accommodate upwards of four persons. On

203

204

Editorials

these suites they would make a rate of $3.00
per day each person, with bath, or $2.00 per
day each person without bath.

For information regarding commercial ex-
hibits and other business matters connected
with the meeting, address the Business 'Man-
ager, Paul B. Hoeber, 67-69 East 59th
Street, New York City.

It is hoped to arrange for special trains
and cars from various sections. Details re-
garding this will be announced later.

Annual Meeting Western Section

The officers of the Western Section of The
American Roentgen Ray Society are mak-
ing plans for their second annual meeting.
They have selected Portland, Oregon, as the
place of meeting, and the time has been set for
Alay 27th and 28th. This time will permit of a
continuous trip for the western men who de-
sire also to attend the A. M. A. meeting in
Boston.

The Pacific Coast Roentgen Ray Societv
will meet at the same time and place, the two
organizations being the guests of the Portland
Roentgen Club, a very active organization of
specialists.

The Secretarv' of the Western Section would
welcome a visitor or two from the East with
papers or demonstrations, and can assure them
of a ver\' enjoyable meeting. Address Dr. War-
ner Watkins, Box 1328, Phoenix, Arizona.

NEW COMMITTEES
Safety, and Laws and Public Policy

At the last meeting of the American
Roentgen Ray Society two important com-
mittees were created, a Committee on Safety
and a Committee on Laws and Public Policv.

The Committee on Safety is charged with
the investigation of all matters pertaining to
the dangers incurred in the practice of roent-

genolog}-, and recommending measures to in-
crease its safety. This will necessitate an ex-
tensive investigation by the committee in
order that it may collect data covering the
experience of as many men as possible. It is
hoped that all members of the Society and
readers of the Journal will cooperate with
the Committee both by sending to it, volun-
tarily, any information that may be of value,
and by answering any questions that may be
sent to them with regard to accidents and
injuries, both electrical and .r-ray, that have
occurred in their practice.

The Committee's recommendations with
regard to the practical value of safety de-
vices, as well as those for the ehmination or
lessening of the dangers pertaining to the
practice of roentgenology, will undoubtedly
be of great value to roentgenologists.

The Safety Committee consists of Prof.
J. S. Shearer, Chairman, Cornell University,
Ithaca, N. Y., Dr. P. M. Hickey, and Dr.
W. D. Coolidge.

The Committee on Laws and Public Policy
was authorized by the following resolution
which states its purpose:

"During the coming year there shall be
appointed by the President at his convenience
a committee of three to be known as the
Standing Committee on Laws and Public
Policy: that it shall be the duty of this Com-
mittee on Laws and Public Policy to keep the
Society informed as to changes in laws and
legal decisions; to cooperate with similar
committees from other medical societies and
public welfare associations, generally, to the
end that this Society shall be found in a
proper attitude toward all matters of legis-
lative and public policy which may be found
to involve the welfare of the Society or prop-
erly to demand the Society's cooperation."
This committee consists of Dr. E. H.
Skinner, Chairman, Rialto Building, Kansas
City, Mo., Dr. Charles F. Bowen, and Dr.
E. A. Merritt.

Any member of the Society who has any
matter which he wishes to bring to the at-
tention of this committee should communi-
cate with the Chairman.

• A. C. Christie.

Editorials

205

SIXTH ANNUAL MEETING
THE AMERICAN RADIUM SOCIETY

Preliminary Program

The Sixth Annual Meeting of The
American Radium Society will be held at
Boston, June 6 and 7. The place of meeting
for scientific work will be the Harvard
Medical School, the headquarters the Hotel
Brunswick. Following is the preliminary
program :

Monday, June 6th, 1^21

Morning Session

A.
B.

Executive Session.
Scientific Session.

Treatment of Primary Carcinoma of the
Vagina luith Radium. Leda J. Stacy, M.D.,
Rochester, Minn.

Treatment of Uterine Cancer by Radium.
Harold Bailey, M.D., Rochester, Minn.

Histologic Changes Occurring in Car-
cinoma of the Cervix following Radiation,
with Special Reference to the Factor of
Distance. Charles C. Norris, M.D., and Nor-
man S. Rothschild, M.D., Philadelphia. (By
invitation. )

Radium in the Treatment of Carcinoma of
the Breast as an Adjunct to Surgery. Ben R.
Kirkendall, M.D., Columbus, Ohio.

Radium Combined with X-Ray Treatment
in Carcinoma of the Breast. George E.
Pfahler, M.D., Philadelphia.

Treatment of Glandular Enlargements
with Radium. Russell H. Boggs, M.D., Pitts-
burgh.

Afternoon Session

A Comparison of Radiation Dosages At-
tainable by Use of Radium on and without
Tumors. Charles H. Viol, Ph.D., Pittsburgh.

Dosage in Radium Therapy. Gioacchino
Failla, E.E., New York.

A Comparison of X-Rays with Gamma
Rays. William Duane, Ph.D., Boston. (By
invitation.)

Hyperthyroidism — Classification — Basal
Metabolism in Diagnosis — Reital and Blood
Findings — Treatment by Radium. R. E.
Loucks, M.D., Detroit, Mich.

Action of Radium on the Blood and
Blood-Forming Organs. Isaac Levin, M.D.,
New York.

Experiences in the Treatment of Naso-
pharyngeal New Growths. Curtis F. Burn-
ham, M.D., Baltimore.

Treatment of Multiple Papilloma of the
Larynx in Children. Gordon B. New, M.D.,
Rochester, Minn.

C. Short Executive Session.

Monday Evening

Annual Dinner.

President's Address. (Lantern slides.)

Tuesday, June /th, 1^21

Morning Session

A. Short Executive Session.

B. Scientific Session.

Radium in Dermatology. Frank E. Simp-
son, M.D., Chicago.

Dosage in Superficial Lesions. William S.
Newcomet, M.D., Philadelphia.

Treatment of Carcinoma of the Rectum.
Douglas Quick, M.D., New York.

Treatment of Prostatic and Bladder Car-
cinoma. Hugh H. Young, M.D., Baltimore.

Treatment of Malignant Disease of the
Bladder. Benjamin Barringer, M.D., New
York. (By invitation.)

Treatment of Brain Tumors by Radiation.
Henry K. Pancoast, M.D., Philadelphia.

Tuesday Afternoon

Clinic at the Huntington Memorial Hos-
pital, by invitation and under the direction of
Dr. Robert Greenough, Director of the
Hospital.

2o6

Editorials

CANADIAN RADIOLOGICAL SOCIETY
Notice of Change of Meeting Place

The Annual Convention of the Canadian
Radiological Society will be held this year
in conjunction with the Ontario Radiological
Society at Niagara Falls, Ontario, May 31
to June 4, inclusive. Members of the C. R. S.
will please take notice of this change.

An invitation is extended to all members
of the profession to be present, as the pro-
gram to be presented will well justify the
time spent.

L. K. PoYNTZ, Secretary-Treasurer.

The Third Congress of the Italian
Society of Medical Radiology

The Third National Congress of Radi-
ology took place in the Institute of Electro-
therapeutics and Radiology in Rome, Octo-
ber 28 to 30, 1920. It was well attended by
radiologists from all parts of Italy, The ex-
hibits of radiological apparatus were large
and of great interest.

The opening speech at the meeting was
delivered by Prof. Ghilarducci, in which he
very ably demonstrated the progress made by
Italian radiology both from a scientific and
industrial standpoint, and showed that they
have been able to maintain a place equal in
importance to that of other countries.

Prof. Bertolotti of Turin also delivered an
interesting lecture on radio-activity in biol-
ogy and chemistry.

Prof. Perussia (Milan) discussed the
radiological researches of the heart and large
vessels, extensively illustrated with clinical
and radiological records of personal study.

Prof. Ponzio (Turin) then discussed fully
the most recent physical and biological dis-
coveries of radio-therapeutics and the practi-
cal results. His statements were strengthened
by a large personal experience in the actual
state of the therapeutics of cancer. This sub-
ject was discussed at length by the leading
clinicians.

The program also included numerous
other talks of most appealing interest show-
ing fully the activity and scientific value of
Italian radiolog'v.

Subscribers to The American Journal of Roentgenology visiting T^ew Tor\ City, are in' '
vited to make the ojfice of The Journal (69 East 59th Street, J^ew Tor/^ their headquarters. Mail,
packages or baggage may he addressed in our care. Hotel reservations will gladly he made for those
advising us in advance; in this case, \indly notify us in detail as to requirements and prices. List of
operations in J^ew Tor\ hospitals on fie in our office daily.

BOOK REVIEWS

The Radiography of the Chest, Vol. I.
— PULMONARY TUBERCULOSIS. By Walker
Overend, M.A., M.D. (Oxon) B.Sc.
(Lend.) Pages 120; 108 Illus. Price $5.00.
C. V. Mosby Company, St. Louis, 1920.

This is a book of moderate size contain-
ing ninety-nine radiograms and nine dia-
grams. The first chapter deals briefly with
technique and the radiographic appearance
of the normal chest. The author then dis-
cusses the classification of lesions and gives
his own, which is a most rational one based
on the clinical course and the radiographic
findings.

The author, who is evidently a clinician as
well as a radiographer, gives a brief digest of
the history, physical examination, clinical
diagnosis, and in some instances, the post-
mortem findings with each radiogram. The
arrangement of text and illustrations is not

altogether good, for in many instances the
notes and radiograms of the same case are
several pages apart, making it inconvenient
to consult the radiogram while reading the
interpretation of the same.

The illustrations are generally good, but
in some cases the entire pulmonary area is
not shown.

In the last chapter there is a brief discus-
sion of various topics, such as the relative
value of clinical and radiographic examina-
tion; incipient tuberculosis; tuberculosis in
the great war; the heart in pulmonary tu-
berculosis, etc.

While not a profound exposition of the
subject, this work of a combined clinician
and radiographer contains material which
should be of interest to both the internist and
the radiographer.

John G. Williams

207

TRANSLATIONS &> ABSTRACTS

Greenough, Robert B., Boston. The Treat-
ment of Tumors by X-Rays and Radium.
(Read before the Fifth Congress of the In-
ternational Society of Surgery, Paris, July
19 to 23, 1920.)

After speaking of the limited knowledge
concerning the biological action of radium, the
writer discusses the results of radiation of liv-
ing tissue, which may be enumerated as fol-
lows: "(i) Living tissue may be destroyed en,
masse; (2) Growth may be temporarily in-
hibited; (3) The rapidity of growth may be
stimulated; (4) The manner of growth may
be modified."

While massive destruction of a complex tis-
sue demands a dose of radiation sufficient to
kill the cells of the different types of the area
involved, the effects of stimulation, inhibition
and modification of growth may be exerted
upon individual cells and individual types of
cells in the tissue area exposed to radiation, de-
pending upon the dosage, the susceptibility of
the cells to radiation, and doubtless upon other
factors of which we have insufficient knowl-
edge at present. In the treatment of non-malig-
nant disease and for palliative (non-curative)
treatment of cancer, all of the cells exposed
need not be destroyed. But to cure cancer by
radiation, the exposure must be shown to be
100 per cent efficient in destroying the disease,
or recurrence is to be expected.

The massive destructive effect of the lethal
dose of radiation is used in the non-metastasiz-
ing carcinoma of the skin in both the squamous
and basal-celled varieties. It is also used in
some of the metastasizing forms of cancer
where the removal is impossible. Here the
insertion method by the use of the bare tubes
of emanation or of the needles holding radium
salts or emanation at their tips, has proved ef-
fective in producing massive destruction. This
method has been employed safely near the sur-
face of the body where normal suppurative
processes and their discharges may take place
without the risk of deep and dangerous infec-
tion. Burying tubes of emanation in deeply
situated tumors has proven unsatisfactory,
either because the dosage has been too small to
be effective or a degenerative process has re-

sulted with secondary infection that made sur-
face drainage necessary. For the treatment of
certain malignant tumors on the surface of the
body where operative removal is impossible, or
in combination with operation, when the opera-
tive procedure alone was insufficient, the inser-
tion of tubes of emanation with the resulting
massive destruction, finds a field of great use-
fulness.

As the absorbed rays rather than the pene-
trating rays produce the greatest effects upon
living tissues, it is probable that the beta rays
are the most concerned in the production of
massive destruction with the radium. For this
reason massive destruction is produced only in
close proximity to the source of radiation.

The phenomenon of temporary inhibition is
shown by the fact that cells exposed to radia-
tion for a certain time remain quiescent for a
considerable period, only to awake to active
and continued growth after the radium effects
have passed away. The time before activity
begins again is variable, in some cases several
years.

That small doses of radiation produce a
stimulant effect upon growth is generally con-
ceded. It is impossible that one dose of radia-
tion should contribute a constituent of growth
that was previously lacking as would be the
case if a plant or an animal were supplied with
a greater quantity of light, heat or moisture.
The primary inhibition of growth followed by
the later increased rapidity of cell division
would appear to justify the assumption that
some damage was done by the radiation and
as a result the normal processes in response to
injury were excited.

In addition to the effect on the tumor, there
is an effect seen in the normal tissue surround-
ing the diseased area. The earliest observable
histological changes after radiation are a new
growth of the cell elements in the blood vessels
and connective tissue. It is impossible to state
how much is due to radiation and how much to
the natural processes or inflammation and re-
pair excited by the damaged tumor tissue.
There is, however, a marked new growth of
connective tissue before any recognizable
change in the epithelial cells is seen.

The modification of growth resulting from

208

Translations and Abstracts

209

the radiation of living tissue depends upon the
tissue investigated to a great extent. Normal
tissues may be made abnormal, and developing
embryonic cells may be made to develop in an
abnormal manner. This ability of radiation is
shown in the clinic in its application to the re-
lief of benign skin lesions such as papillomas
and keratoses. In these the destructive effects
are not needed or desired. After a mild reac-
tion the deeper cells which were formerly
growing in an abnormal manner begin to grow
more normal. The abnormal cells are cast off
and the lesion heals without a scar. While this
action is of greatest value in the treatment of
non-malignant lesions, it can be counted upon
but little in the attempt to eradicate malig-
nant disease. No modification of growth of
cancer cells short of death and destruction of
every cell is sufficient to cure the patient of
cancer.

The so-called "selective action" of radium
upon tumor tissue is next considered. Some be-
nign lesions such as papillomas and keratoses,
which yield to the "modifying" effects of ra-
dium without the destructive effect, are of the
class of so-called "precancerous" lesions, but
this does not permit us to presuppose a similar
reaction when dealing with cancer tissue.

Different tissues show a variation in sensi-
tiveness to radiation. Lymph-adenoid tissues
and those of the ovary and testicle are es-
pecially sensitive. Certain tumors of lymph-
adenoid tissue, such as malignant lymphoma
(Hodgkin's disease) and lympho-sarcoma ap-
pear to exhibit a definite and positive sensitive-
ness, in that when they are first subjected to
deep radiation, the tumor masses shrink and
occasionally disappear, without undue damage
to the normal tissues overlying. But it has been
the experience of the writer, that the changes
are temporary, and although a recurrence of
the tumor masses in the same or in other lymph
nodes may again react to radiation, sooner or
later the sensitiveness is lost. In myeloid leu-
kemia, profound changes in the blood picture,
in the size of the spleen, and in the patient's
comfort result from deep radiation of the
spleen, but again the improvement is tempor-
ary. These two diseases are often evoked as
evidence of the selective action of radium. This
action, however, is one of modification of
growth, or even possibly of stimulation of cer-
tain types of tissue, rather than a destructive
effect.

The cells of the ovary and testicle are, again,
notoriously susceptible to radiation. Ovarian
function and menstruation can be brought to
an end by intra-uterine applications of radium,
and with all of the symptoms of the meno-
pause. Azoospermia has been frequently found
in male .^^-ray workers, although there is reason
to believe that recovery from this condition
may subsequently occur when exposure ceases.

When cancer is superficial and accessible to
direct radiation of any desired dosage, either
by surface applications or by insertions, it can
often be permanently destroyed. In no case of
actual cancer, however, has the writer seen
success in this purpose without the production
of a destructive lesion, and in many there is a
failure to destroy the disease entirely. In some
cases, as when a basal cell carcinoma involves
the bones of the face or a carcinoma of the
tongue extends into the tissues of the floor of
the mouth, the cancer tissue seems to be more
resistant to radiation than the normal issue in
the vicinity. In these cases, at least, no specific
sensitiveness is manifest.

Advanced cases of cancer of squamous cell
or glandular origin which have extended to the
regional lymph nodes are frequently subjected
to treatment with radium. The enlargement of
the regional nodes is commonly accepted as
evidence of extension having taken place.
However, it must be remembered that other
causes for the enlargement of the lymph node
exist and that it is not at all uncommon to see
an inflammatory process in regional lymph
nodes due to the ulceration of the primary car-
cinoma. Even in the presence of a certain
amount of infiltration of cancer cells, inflam-
matory changes may occur and lead to fluctua-
tion in the size of the lymph nodes far too
rapid to be interpreted as being due to cancer
growth alone. In almost every fatal case of car-
cinoma of squamous cell or glandular origin
extension of the disease into the regional lymph
nodes ultimately takes place. In none of these
cases has the writer seen a permanent destruc-
tion of the disease following radiation. Shrink-
age in size of a large node is obsei-ved, but he
is inclined to attribute this, when it occurs, to a
change in the accompanying inflammatory pro-
cess rather than to a destruction of cancer
tissue.

Cells engaged in mitotic division are gen-
erally believed to be more sensitive to radia-
tion than resting cells. The large number of

2IO

Translations and Abstracts

mitotic figures is a characteristic of cancer tis-
sue. It is not unreasonable to suppose that a
part, if not the greatest part, of the supposed
sensitiveness of cancer tissue to radiation is
dependent upon the number of cells actually
undergoing mitosis during the period of ex-
posure. If this is so, a fractional destruction of
the tumor only can be expected as a result of
repeated deep radiation, for during each ex-
posure only those cells then in mitosis would be
affected, and a diminishing but constant res-
idue of unaffected cells would always remain to
awaken into activity and grow at some subse-
quent time and produce recurrence. It must be
recognized that there is abundant evidence that
repeated exposure to radiation produces a
gradual loss of sensitiveness on the part of
the tissues exposed, so that the attempt to ac-
complish a fractional destruction of tumor
tissue by deep radiation is by this fact, also,
made more difficult. The clinical observations
of the result of deep radiation on cancer tissue
are in accord with this theory, for although
inhibition or retardation of growth mav be
observed, the destruction of the tumor and the
cure of the disease are not accomplished.

In general, the experience in the clinic and
in the laboratory has shown that the massive
destructive effect of radiation (by direct ap-
plication) is necessary for the cure of the
disease.

While certain tissues show a sensitiveness to
deep radiation which is of value in the treat-
ment of non-malignant disease and in the pal-
liative (non-curative) treatment of malignant
disease as well, the cure of cancer (estimated
in surgical terms on a three to five year basis)
is not accomplished without the massive and
total destruction of the tumor by the direct ap-
plication of the source of radio-activity.

K. F. Kesmodel.

Quick, Douglas. The Combination of Radium
and the Z-Ray in Certain Types of Car-
cinoma of the Breast. (Surg., Gynec. &
Obst., Vol. xxxii, No. 2, Feb., 1921.)

The writer reviews the existent literature
briefly, and quotes some interesting early re-
sults. He notes that in the past, radium and
.r-ray have not been sufficiently combined. He
describes the technique in use at the ^Memorial
Hospital for burying emanation tubes in the

tissue; presents an outline of the histologic
changes which follow such a procedure and
which furnish a rational basis for radium
therapy. He thinks that the results following
the burial of small emanation tubes (2 or 3 mc.)
are better than those following the same total
dosage delivered in a shorter time. Filtration,
in this method, is through a thin glass wall
only, and this permits the use of nearly all of
the beta radiation — a very important factor.
Subsequent jr-ray treatment is carried out as
though no radium treatment had been given.
During the past two and one-half years, 78
cases of carcinoma of the breast have been thus
treated at the Memorial Hospital. Of these, 7
show complete regression, and have remained
well for periods of from three months to two
years; 21 cases show a partial regression, and
are still progressing (no case in this group has
been observed less than five months) ; 24 cases
showed temporary benefit; 19 of these have
died, but without fighting up of the original
process; 10 cases showed no improvement
(these were far advanced cases with wide-
spread metastases) ; 9 cases were not followed ;
7 cases have been imder observation too short
a time for any report; 12 of the foregoing
cases are reported in detail, with micro-photo-
graphs illustrating the histologic changes oc-
curring; 58 of these cases were treated for
recurrences and metastatic growth; only one
of these was operable. He notes that radium
seems to control the pleural pain better than
.r-ray. He concludes that the .r-ray is useful in
the treatment of every case of mammary car-
cinoma ; that radium may be combined with
.r-ray to great advantage in a certain number
of cases ; that radium is useful mainly in flat
or bulky recurrences, axillary involvement, in-
operable primary cases; and in cases refusing
operation ; and that radium and .r-ray may
convert an inoperable case into an operable
one at times. Lowell S. Goin.

Baejter, F. H., and Friedenwald, Julius.
Roentgenological Aspects of Lower Right
Quadrant Lesions. Am. J. Med. Sc, No-
vember, 1920, clx, 639.

The importance of lesions of the right lower
quadrant is quite evident. Among the most
frequent lesions occurring in this locality may
be mentioned :

Translations and Abstracts

211

1. Appendicitis.

2. Incompetent ileocecal valve and ileal
stasis.

3. Dilatation of the cecum with retention.

4. Adhesions and angulations.

5. Ulcerations due to tuberculosis.

6. Ulcerations due to carcinoma.

Both bismuth meal and enema are employed.
The ingested meal should reach the cecum in
five to eight hours, according to the meal em-
ployed. Delay in the passage of the meal may
be due to dilatation of the cecum, to ptosis
or adhesions, to ileal stasis and angulation,
ulceration or carcinoma. A bismuth enema,
given in the knee-chest position, is also of
advantage in studying lesions of the right
lower quadrant.

I. Appendicitis. — Acute appendicitis may
be more accurately diagnosed by fillmg the
cecimi to localize the site of involvement and
then (in certain instances where the onset of
a lower right pneumonia is preceded by symp-
toms simulating appendicitis) to rule out in-
volvement of tliis organ by showing the ab-
sence of a painful point over the cecum or any
limitation of mobility.

Chronic appendicitis : The appendix can be
examined only if the lumen is potent and will
admit bismuth; otherwise it cannot be visual-
ized. The specific technique emphasized by
Case for examination of the appendix is as
follows :

(i) Examination of the patient on the hori-
zontal fiuoroscope. The tube must be under
the table and the screen over the abdomen, to
insure the proper examination.

(2) The abdomen must be palpated with the
gloved finger or a spoon for localization of a
point of tenderness.

The time of examination is of importance.
In six hours the cecum fills, and under palpa-
tion the appendix may fill. From then on until
the bowels are empty it may be visible. When
the appendix remains visible for more than a
day or two after the bismuth examination it
is a dangerous appendix. The bismuth-filled
apf)endix has been noted weeks after an ex-
amination. Where there is no local tenderness
on pressure, appendicitis can usually be ex-
cluded. Where the cecum is limited in motion
there is always the possibility that this may be
due to inflammation even if the appendix is
visualized and not tender. The frequency of
visualization of the appendix with bismuth

meal varies with different men — 35 to 90 per
cent. Not every visualized appendix is abnor-
mal. The mere filling of the appendix does not
necessarily indicate pathology. When it is
curled up, kinked or bound down it probably
is pathological.

The stomach is often pulled toward the right
lower quadrant due to omental adhesions. As
a reflex condition chronic appendicitis may
give rise to a picture similar to that of duo-
denal ulcer; gastric and duodenal hypemio-
bility, with a definite filling defect of the
duodenal cap.

2. Incompetent ileocecal valve and ileal
stasis. — In one sixth of 3000 cases examined
by Case incompetency of the ileocecal valve
and ileal stasis was noted. Bismuth meals
which after twenty- four hours had completely
left the ileum were found at thirty-six and
forty-eight hours to have regurgitated through
an incompetent ileocecal valve into the ileum.
The patient should be on his back on the
horizontal fiuoroscope. The rectal point should
be inserted not more than one or two inches.
The container of the barium enema should
never be elevated more than two feet. Ordi-
narily 1200 c.c. (100° F.) will fill the colon
without causing irritation. The cecum must
be well filled and palpated under the fiuoro-
scope. Plates should be made with the patient
in the prone position. When a bismuth meal
is given it collects in the terminal ileum in
about four hours and leaves in eight to nine
hours. Delay in passage may be due to spasm,
incompetency of the ileocecal valve, bands of
adhesions, displacement, prolapse or tumors ;
dilatation of the terminal ileum points to
obstruction.

3. Dilatation of the cecum with retention. —
The ingested bismuth meal appears usually in
the cecum in from seven to ten hours. Delay
in passage may be due to dilatation and reten-
tion of cecum. This may be associated with
constipation, appendicitis, sub-acute inflamma-
tory lesions, or enteroptosis. It is not the po-
sition of the cecum which is most important
but the function of this part of the bowel.
The constipation associated with this condition
may be very marked and on operation the re-
tained fecal material may cling closely to the
walls of the cecum leaving bleeding areas '
when separated, showing evidence of a sub- ■
acute infection. '/

4. Adhesions and angulations. — Angulations

212

Translations and Abstracts

and kinks occurring in the right lower quad-
rant are often due to adhesions either from
appendiceal disease, pelvic inflammation or
some local inflammatory process. The delay in
the passage of the bismuth will give a clue to
this.

5. Ulcerations from Tuberculosis. — The
clinical picture of intestinal tuberculosis is of
little aid in early cases. The roentgenographic
examination may give definite information.
The most constant finding is intestinal hyper-
motility, the entire meal being discharged in
twenty to twenty- four hours ; this may be with
or without gastric residue. A spastic condi-
tion of the bowels affecting especially the ce-
cum and ascending colon is noted and often
irregular filling defects can be seen.

6. Ulcerations from carcinoma. — There is in
this condition a large irregular constant filling
defect of the cecum. Filling defects from ad-
hesions and fecal contents must be carefully
differentiated by re-examination at a later date.

In conclusion, the .r-ray examination should
be looked upon as an aid in the diagnosis of
the lesions above indicated. The possibility of
error is so great that mistakes will necessarily
be made. If the roentgen diagnosis is diamet-
rically opposed to the clinical and all other
findings it is probably wise to adhere to the
clinical interpretation.

L. R. S.

Hernaman-Johnson, Francis. The Use of
X-Rays as Immunity-Raising Agents before
and after Operation for Cancer. (Brit. Med.
J., June 12, 1920.)

The knife may be a means of disseminating
stray cancer cells. If before this occurs we can
bring about either a weakening of the malig-
nant cells or an increase in the resistance of
the body tissues, or both, the chance of suc-
cessful colony formation by the parent growth
will be lessened. Experimental research has
shown that mouse cancer which has been ex-
posed to radiation is grafted into fresh tracts
Avith difficulty or not at all. Clinical evidence
supports this fact as applied to man. The
^--rays act as much by their stimulating or
regulating action upon the body as by their
depressing effect upon cancer. Embnonic cells
are injured or destroyed by doses of radiation
which have little or no effect upon the normal

tissue. The general stimulating and regulating
action of the ;r-rays is of more value than their
specific effect upon the pseudo-embryonic cells.
The immunity produced by A'-rays is partial
and non-specific. It is not proven that that
resulting from the use of radium is any differ-
ent. Pre-operative treatment should be given.
The healing of the wound is not delayed and
the only argument agamst such a procedure is
that it delays operation for two or three weeks.
This argument, to be valid, implies that the
cancer, though improving visibly, is invisibly
spreading in depth. This does not occur. If
immunity to cancer can be raised by pre-op-
erative raying, we should obviously carry out
raying after operation. So long as we are not
dealing with actual recurrence, we should be
careful to give too little rather than too much.
The fact that small doses increase the immun-
ity to cancer and that large ones decrease or
abolish it must be kept in mind.

Lowell S. Coin.

Marty, L. A. The Modern Treatment of
Malignancies. (/. Missouri Med. Assn. Vol.
XVII, No. 7.)

In the United states 65,000 people died of
cancer in 1918; 200,000 people are suffering at
all times from this condition. We are no
longer justified in "cutting it out" and allow-
ing the percentage of recurrences to be high
and the mortality what it is at present. Only
the man doing .ar-ray work and radium therapy
will be able to do work that is fair to the
patient, for specialists are not made over night
in this more than in any other special branch.
Breast cases, for example, should have prelim-
inary raying to block the lymphatics and lower
the vitality of the malignant cells. A massive
dose should be delivered into the wound be-
fore closure of the flaps and post-operative
raying should be begun as soon as the patient
has recovered from the shock of the operation.
The axillary and clavicular regions, and in
fact the entire chest should be rayed. The same
applies to malignancy elsewhere. In cancer of
the pelvic organs radium may be added to
advantage. Radiation is indicated in every case,
as much suffering is relieved, toxemia less-
ened, and the patient made more bearable to
those about him.

L. S. G.

Translations and Abstracts

213

HuBENY, M. J. Z-Ray Treatment of Exoph-
thalmic Goiter. (Illinois Med. J. June, 1920,
P- 383.)

The writer reviews briefly the history of
;i;-ray therapy in goiter and sums up the histo-
logic basis for such treatment. He has used
two techniques, one is to give each of these
areas (including the thymus) two thirds of an
erythema dose, using a 9 inch spark-gap and
filtration of 4 millimeter aluminum and one
millimeter leather with target skin distance of
8 inches. This dose is repeated in three weeks.
The second technique consists in using the
same filtration, the same spark-gap and a 14
inch skin distance, applying a half -erythema
dose over each of six areas: right anterior
thymus; left anterior thymus; right anterior
thyroid; left anterior thyroid; right and left
posterior cervical ganglionic areas. Roentgen-
ization over the cervical ganglionic areas in-
hibits thyroid secretion. The second technique
is preferred when the patient is not highly
toxic, quicker results are obtained with the
first technique. Early treatment increases the
chances of recovery, exophthalmos disappears
in 40 per cent of cases. The first dose should
be small to guard against an increased toxemia.
Caution should be used in treatment of cases
after operation, as there is danger of the pro-
duction of hyperthyroidism,

L. S. G.

FiscHEL, Ellis. The Use of Radium in Car-
cinoma of the Face, Jaws and Oral Cavity.
(/. Missouri Med. Assn. Vol. XVII, No. 7.)

. The recognized methods of treatment are
operative removal, destruction by x-vdcy, ra-
dium, high frequency or the actual cautery.
The ;r-ray can be relied upon to cure nearly
all basal cell epitheliomas of the fact. At pres-
ent it cannot be depended upon to destroy the
more malignant types even when located on
the surface. The writer has never seen a lesion
located within the mouth benefited by the
;r-rays. Radium has some advantages over the
x-x2iy, particularly the fact that a known
amount may be buried in a mass. Whatever
means are employed, the tumor should be de-
stroyed as completely as possible at the first
attempt. If cancer of the lip, the results under

radium treatment have been so striking that
operation is no wreserved for those who have
had paste or unsuccessful operative treatment
before. Results within the oral cavity have not
been so successful, no cures having been noted.
If the growth involves the bony jaw, operation
is advised, and is followed by radium.

L. S. G.

ViLRANDE, G. E. Observations on the Treat-
ment of Neoplasm. {Brit. Med. J., February
14, 1920.)

The writer reports a number of interesting
case histories of various malignancies treated
by radium. He thinks that there is no doubt as
to the value of radiation of the site of glands
after removal, and pleads for the routine ray-
ing of the scars after lip operations. Rodent
ulcers do best under radium. Sarcomata are
much more easily inhibited than are carcino-
mata. Breaking down malignant glands as fol-
low an epithelioma of the lip, does not do well
under ;tr-ray treatment. Neoplasm of the lungs
reacts to hard, heavily filtered rays, but the
writer has not seen one disappear. He suggests
that perhaps the frequent occurence of epi-
thelioma on lupus that has been treated by
small doses of unfiltered rays may have some
significance. Larger doses of harder, more
heavily filtered rays are indicated in radio-
therapy. The writer has doubled and tripled
his dosage in the past two years.

Leighton, W. E. Inoperable Cancer. (/.
Missouri Med. Assn. Vol. XVII, No. 7.)

The responsibility for inoperable cancer
rests (i) with the quack cancer specialist, (2)
with the patient who neglects to consult a
physician, (3) with the physician who fails
to recognize the disease, or who attempts su-
perficial surgery. The diagnosis of external
cancer is not very difficult. Ulcerations which
do not heal readily should arouse our suspi-
cions, and tumors of all descriptions demand
early investigation. The laity and the phy-
sicians must be educated to the fact that early
diagnosis and operation will cure a large per-
centage of cancer cases. Palliative operation
should be undertaken where possible. The re-

214

Translations and Abstracts

moval of ulcerating and offensive masses by
cauterization, electro-thermic coagulation or
electric dessication may accomplish wonders.
Deep roentgen therapy after removal of the
skin has given excellent results.

L. S. G.

dose. After two weeks half-pastille doses may
be given at ten-day intervals. Local relapse
is rare.

Acne can be permanently cured, no matter
in what stage it may be, by judicious ;r-ray
treatment. L. S. G.

Semon, H. C. The X-Ray Treatment of Acne
Vulgaris. (Brit. Med. J., May 22, 1920.)

The etiology and pathology of acne is
that the effect of the rays on acne lesions is
the inhibition of the physiologic action of the
secretory cells of the sebaceous glands, and
the dissolution of the fibrous capsules of the
infected comedo. Whether or not this is cor-
rect, it remains a fact that the .ar-rays will
cause involution, both of the comedo and the
deep nodular abcsess and reduce scarring to
a minimiim. For simple cases unfiltered rays
from a tube backing up between 4 and 5 inches
spark-gap are used, giving a dose of four
fifths Sabauraud B tint. This is not repeated
within ten days. An erythema is not desirable.

When pustulation and dermatitis are
marked, treatment is preceded by a few days'
application of antiseptics and detergent lo-
tions, after which doses of two-fifths B tint
are given at ten-day intervals. In the more
advanced stages, with intra- and sub-dermic
nodules, periglandular fibrosis, etc., harder
rays from a tube backing up between 5 and 6
inches of spark-gap are used, with five milli-
meters of aluminum filter, giving a full pastille

Bryan, Lloyd. The X-Ray as an Aid in Diag-
nosis of Non-Tubercular Pulmonary Condi-
tions. (California State J. Med. Vol. XVIII,
No. 6.)

Lung abscess is seen as an irregular area of
increased density, fading out gradually into
normal lung tissue. If the cavity is only partly
filled with fluid, a gas bubble may be seen
above the fluid level. The large area of con-
solidation about the cavity may be misleading,
and the surgeon will be disappointed in finding
so small a cavity. Abscess must be differenti-
ated from bronchiectasis in which condition
the indurated areas are usually multiple. The
peribronchial thickening of bronchitis never
reaches the periphery. Primary and secondary
pulmonary malignancy must be differentiated
from both lung abscess and tuberculosis. Meta-
static sarcoma give a picture identical with
that of multiple small abscesses. Tuberculosis
may be confused with pneumoconiosis, and
may be coincident with it. Diagnosis should
not be made from an x-x2cy examination, which
is only an aid, and must be correlated closely
with the clinical findings.

L. S. G.

THE AMERICAN JOURNAL
OF ROENTGENOLOGY

Editor, H. M. Imhoden, M.D., 7<iew Torl^

VOL. VIII (NEW SERIES)

MAY, 1920

No. 5

THE ABSORPTION OF RADIUM RADIATIONS BY TISSUES

By GIOACCHINO FAILLA, E. E.

Physicist to the Memorial Hospital

NEW YORK CITY

HIS investigation was undertaken for
the purpose of determining the absorp-
tion by different tissues of the radiation of
radium filtered through various thicknesses
of metal. The scope of the work was to
apply the knowledge thus obtained to radium
therapy.

DESCRIPTION OF APPARATUS

The apparatus used for the experiments is
shown in Figure i. The conical ionization
chamber is made of lead, and is supported
vertically on a suitable frame not shown in
the diagram. It is 51 cm. long, 3 cm. in
diameter at the smaller end, and 12 cm. at
the larger end. The wall thickness is 0.8 cm.
A thin steel rod, tapered to a point, is sus-
pended along the axis of the chamber, and
is carefully insulated therefrom. The rod is
electrically connected to the leaf post P of
the electroscope by means of a fine copper
wire which runs through brass tubes filled
with paraffin. The electroscope is made of
lead I cm. thick. The inside dimensions are
2.7 by 6 by 7 cm. It is arranged (as shown
in the lower part of the figure) so that the
gold leaf is projected on a ground glass
screen. The lead cone, brass tubes, and elec-
troscope case are all connected to the ground

at G. The gold leaf of the electroscope is
charged by pulling a string attached to a bell
crank, so that the rod R, which is connected
to a suitable source of potential, touches the
leaf post. The wire in the ionization chamber
will then be at the same potential as the leaf.
The charging potential is adjusted so as to
bring the image of the leaf always to the
same point a on the screen. In taking read-
ings, the observer sits in front of the ground-
glass screen, and, with a stop watch, meas-
ures the time it takes the image of the leaf
to travel between the points b and c on the
screen.

The supports for the source of radiation,
filter, and tissue, are made of hard rubber
and very thin mica, as shown at AB. They
are placed at such a distance from C that the
source of radiation is practically at the apex
of the cone. In this manner the beam of rays
which enters the cone fills the whole cham-
ber. The metallic filters are placed just aboye
the radioactive source; the tissue is placed
on the mica window B which is 1.5 cm. above
the support for the filters. With this arrange-
ment it is possible to change the filter with-
out disturbing the tissue in any way. The
lower end of the ionization chamber Is closed
by a very thin sheet of mica.

The radiation we wish to measure is only

215

2l6

Absorption of Radium Radiation by Tissues

the beam which enters the ionization cham-
ber. It is necessary, therefore, to shield the
electroscope itself from the radiation which
the source emits in all directions. For this
purpose a thick block of lead is interposed
between the source and the electroscope, and
the latter is so constructed that no stray
radiation can enter it. The brass tubes are
filled with paraffin for the same purpose of
limiting the effect of the radiation to the air
in the ionization chamber proper. The instru-
ment was tested to see whether the shield-
ing was sufficient, and it was found that the
effect on the electroscope which was not due
to the ionization chamber was negligible.
Account had to be taken, however, of the
"natural leak" of the instrument, that is, of
the slow discharge of the electroscope leaf
when the source of radiation which we
wished to investigate was not present. This
correction is made by subtracting the rate of
fall of the leaf due to the natural leak alone
from the rate of fall due to the combined
effect of the radiation which enters the ion-
ization chamber, and the natural leak.

It is important to bear in mind just what
we are measuring with an apparatus of this
sort, because on that depend the conclusions
which we may draw from the experimental
results. The cone of rays which enters the
ionization chamber ionizes the air in it. The
formation of ions implies that energy is
being used up in the process, since work must
be done to separate negative from positive
electricity on account of the force of attrac-
tion between the two. This energy is supplied
by the radiation. The difference of potential
between the wire and the walls of the ioniza-
tion chamber is sufficient to cause the posi-
tive and negative ions to be separated from
each other as soon as they are formed, thus
preventing their recombination. Under these
conditions the electric current thus produced
is proportional to the number of ions pro-
duced per second, which is a measure of the
energy absorbed by the air in the chamber.
The electroscope, used in conjunction with a
stopwatch, measures this ionization current.
Consequently the readings which we obtain

in this manner are proportional to the energy
absorbed.

The physiological action of radiation is
dependent to a considerable extent on the
amount of energy absorbed by the radiated
tissue. It is evident, therefore, that ionization
methods of measurement offer a good basis
for the correlation of the physical factors of
the dose of radiation administered and the
physiological effects produced thereby. The
method, however, has its limitations, which
should be clearly recognized. In the first
place, the medium in which the ionization is
measured is a gas, and not tissue. When the
constituents of the gas do not differ very
much in atomic weight and relative propor-
tions from the constituents of tissue, the ab-
sorption of radiation, mass per mass, is sub-
stantially the same. If we assume this to be
true in the case of air, the thickness of tissue
equivalent to the air in the ionization cham-
ber of these experiments is about 0.6 mm.
Secondly, the ionization of the air in the
chamber consists of two parts, that produced
directly by the passage of the beam of radia-
tion through the air, and that produced by
the scattered and secondary radiation ex-
cited by the rays which impinge on the walls
of the chamber. When a metal ionization
chamber is used, as in this case, the second
term may be very important, according to
the character of the radiation. Thirdly, the
scattered and secondary radiations, which
contribute to the effect in a deep-seated
tumor, for instance, are quite different
from their counterparts in the ionization
chamber. These are the main physical differ-
ences between the conditions obtaining in
laboratory experiments and in the treatment
of patients. It is evident, however, that there
are greater differences which are independ-
ent of physical conditions, but which are due
to the inherent peculiarities of living matter.
The physiological action of radiation de-
pends not only on what takes place in the
radiated tissue, but also on the reaction of
the whole system. Naturally we cannot simu-
late this in physical experiments. Hence, in
order to make practical application of the

Absorption of Radium Radiation by Tissues

217

results obtained from physical experiments,
it is necessary to conduct physiological ex-
periments complementary to the former.

EXPERIMENTAL PROCEDURE

To determine the absorption of radiation
by tissue it was necessary to have uniform
parallel slices of tissue about 5 cm. square.
The thicker slices were cut by hand, using
a knife with a wide blade. The thin slices

case of a very soft tissue, because its weight
flattened the bottom layers. The density of
the tissue was determined as follows: The
tissue, in one or several pieces, was weighed
with an accurate balance. Its volume was
then determined by measuring the amount of
water which it displaced, and the density
obtained by dividing the mass by the volume.
The weight of the tissue used for this de-
termination was in every case several hun-
dred srrams. For the metals and solid bone

Fig. I. Projection of Go/d Leaf on Grounol Glass Screen

were cut by means of a meat-slicing machine
with a specially ground knife, after the tissue
had been frozen hard. Tissue hardened in
formalin could be cut with this machine
without trouble. The thickness of the slices
of tissue was determined by placing each
between two thin sheets of lead and measur-
ing the total thickness with a micrometer
caliper. When the thickness of tissue on the
mica support was several centimeters, the
total thickness was checked by placing a
steel scale against the pile of tissue. This
procedure was especially necessary in the

the volume was calculated from the dimen-
sions of a rectangular slab of the material.
The source of radiation used for these
experiments was radium emanation enclosed
in capillary glass tubes about 0.5 mm. in out-
side diameter and 14 mm. long. While the
wall thickness of these tubes is sufficiently
great (about o.i to 0.15 mm.) to absorb the
alpha rays, it has little effect on the beta and
gamma radiations. If such a tube, containing
a suitable amount of emanation, is placed at
A in the apparatus of Figure i, the radiation
will go through the very thin mica sheets at

2l8

Absorption of Radium Radiation by Tissues

B and C and will enter the ionization cham-
ber without appreciable absorption. There it
will ionize the air, and the electroscope will
measure the ionization thus produced. Let us
arbitrarily call the intensity of ionization in
this case lOO units. If we place a slice of
tissue I mm. thick on B, the radiation which
enters the ionization chamber is only that
part of the original beam which succeeded in
getting through i mm. of tissue. This pro-
duces an ionization of 43 units in the cham-
ber as measured by the electroscope. The
addition of another millimeter of tissue (a
total thickness of 2 mm.) reduces the ioniza-
tion to 27 units. Continuing in this manner,
for larger thicknesses of tissue, we obtain
values of the intensity of ionization for
dififerent thicknesses of tissue interposed be-
tween the source of radiation and the ioniza-
tion chamber. The results are^shown graphic-
ally by curve A in Figures 3 and 4. A similar
procedure using a metal or a metallic filter
and tissue enables us to obtain the alDsorption
curves shown in Figures 2, 3, and 4.

DISCUSSIOX OF ABSORPTION CURVES

In these experiments the ionization pro-
duced by the total radiation, beta and
gamma, emitted by an emanation tube, was
assumed to be 100 units. All other readings,
therefore, represent percentages of the total
radiation. As the range of values to be in-
corporated in the absorption chart is large,
it was thought best to use a logarithmic scale.
In this way, as the values decrease the scale
is automatically increased. Furthermore, a
logarithmic scale has the important advan-
tage that it enables us to tell at a glance when
the radiation becomes "homogeneous," be-
cause in this case the absorption curve is a
straight line. For our purposes the radiation
is homogeneous when successive equal lavers
of tissue absorb the same percentage of the
radiation which reaches them. This means
that the quality of the radiation remains sub-
stantially the same as it goes through the
filter or tissue.

In Figure 2 are shown the absorption

curves for different metals. It will be seen
that the curves for metals of medium or low
atomic weight become straight lines beyond
a thickness of metal of a few millimeters.
The curve for lead, on the other hand, does
not become straight in the range of thick-
ness shown in the chart. The mathematical
law of absorption which applies to the
straight part of the curve is
I = I„e-/xd

where lo^ intensity of radiation falling on
filter,
I = intensity of radiation passing

through the filter,
d = thickness of filter,
e = Naperian base of logarithms,
/x, = the coefficient of absorption.
The coefficient of absorption represents
the fraction of the incident radiation which
is absorbed or scattered per unit thickness of
filter.* For the same quality of radiation,
this is different for different absorbers, and
for the same absorber it is different for dif-
ferent qualities of radiation. In the case of
aluminum, for instance, the value obtained
from the curve of Figure 2 is o.ii, and
therefore 1 1 % of the gamma radiation is ab-
sorbed per centimeter of aluminum. (The
value given by Soddy and RusseP is o.iii,
and by Rutherford and Richardson" is
0.115.) In the case of brass the value of /^
for gamma rays is 0.35, so that brass ab-

0.35 ,.

sorbs — ^ — = ■\.2 tmies more gamma radia-
o.ii ^

tion per unit thickness than aluminum. The

thickness of lead used in these experiments

(2 cm.) was not sufficient to give a straight

line in the absorption curve. Hence it is not

strictly correct to speak of a coefficient of

absorption for this curve. However, if we

make the calculation for the last part of the

curve we find that m equals 0.58, which is

somewhat higher than the value of 0.5 given

by Rutherford." This shows that the hard-

* In thinkinsr of the coefficient of absorption in these
terms, care should he exercised to choose a unit o£
thickness which will make the amount of radiation
absorbed by a filter of unit thickness a small fraction
of the incident radiation.

Absorption of Radium Radiation by Tissues

219

ness of the gamma radiation from radium
increases with the thickness of filter beyond
2 cm. of lead. In fact, from the experiments
of Tuomikoski* and others, it appears that
the penetration of the gamma radiation of
radium increases even after filtration by sev-
eral centimeters of lead. Such excessive fil-
tration, however, is entirely out of the ques-

the aluminum and brass curves become
straight lines beyond a thickness of a few
milllimeters indicates that radium radiation
filtered through 6 mm. of aluminum or 2
mm. of brass is sufficiently homogeneous to
be absorbed by these metals according to
the exponential law given above, within
the range of thicknesses shown in Figure 2.

Figure 2.

tion in radium therapy, on account of the
weight of the filter and the diminution of
the quantity of radiation which passes
through it. Even for 20 mm. of lead the
ionization produced by the transmitted radia-
tion is only 1.5% of the value for the un-
filtered beta and gamma radiation, and less
than 54 the value for radiation through i
mm. of lead.

Fortunately no such filtration is necessary
in therapy. In the first place, the fact that

The reason is that for substances of low
atomic weight the coefficients of absorption
as here defined do not vary much with the
wave length, for gamma radiation of the
quality considered.^ A fortiori this is true of
the absorption of tissue, the principal con-
stituents of which are much lighter than
these metals. Iji the case of lead, the mechan-
ism of absorption is further complicated by
the fact that the element is an isotope of
Radium B.*

220

Absorption of Radium Radiation by Tissues

In Figures 3 and 4 are shown the curves
of absorption by tissue of the radiation fil-
tered through different thicknesses of brass
and lead respectively. The circles indicate
the points which were experimentally de-
termined. The largest thickness of tissue
used in these experiments was about 7 cm.
For this reason the prolongation of the
curves to 10 cm. is shown in dotted lines.
We are justified in extrapolating to 10 cm.
because many other curves we have obtained
in the course of our work, using up to 9 or
10 cm. of tissue, have been straight lines,
within the limits of experimental error.
In either chart the highest curve is for the
total radiation, beta and gamma, emitted by
the small capillary glass tube containing ra-
dium emanation. It will be seen that there
is a sharp bend in the curse corresponding
to a thickness of about i cm. of tissue. This
is the point at which a transition occurs in
the quality of the radiation, from a prepon-
derance of beta and soft gamma rays to a
preponderance of hard gamma rays. The
presence of soft radiation is evident, how-
ever, even up to thicknesses of tissue of 5 or
6 cm. ^

The lowest curve, F, in either set repre-
sents the absorption of radiation by the metal
filter alone. These curves are the same as
shown in Figure 2, but plotted to a different
scale. The absorption cur\-es for filtered radi-
ation branch out from these curves. The
filters used were approximately i/<, 1,2, and
3 mm. of either brass or lead. For any point
on the curve the thickness of tissue is added
to the thickness of filter. Thus for the third
curv^e, C, in Figure 3, we have: a brass filter
0.96 mm. thick reduces the ionization from
100 to 7.6%, the further addition of i cm. of
tissue brings the ionization to 6.2%, and so
on. The curves are plotted in this manner
so that each is a complete absorption curve,
starting with unfiltered radiation.

For deep therapy it is essential to use
radiation which is absorbed exponentiallv bv
tissue; that is, radiation which is absorbed
to the same extent by successive lavers of
tissue. If this is not the case, the skin and

superficial layers will absorb a larger per-
centage of the incident radiation than corre-
sponding layers of tumor tissue, and there-
fore will be affected more strongly, even if it
were possible to use a parallel beam of radia-
tion. As the dose is adjusted so as xiot to
injure the skin, it follows that by using a
filter w^hich does not give a homogeneous
radiation, the tumor does not receive as
much radiation in proportion as it would if
sufficient filtration were used. Thus, if the
filter consists of ^ mm. of brass, from
Figure 3 we see that the first centimeter ab-

14-5 — 6.4

sorbs

14-5

56% of the incident

radiation, the second centimeter absorbs 9%,
but the third and each subsequent centimeter
absorbs only 7.7%. On the other hand, using
2 mm. of brass as a filter, the first centimeter
absorbs 10%, the second, third, etc., 7.5%,
and the difference, which in this case is due
to the secondary radiation of brass,^ is small.
The further addition of a secondary filter of
2 or 3 mm, of rubber, which has about the
same absorbing power as tissue, makes the
percentage absorbed by the first and succes-
sive centimeters of tissue the same.

The criterion for the exponential absorp-
tion of radiation is that the absorption curve,
when plotted to a logarithmic scale, be a
straight line. From Figures 3 and 4, there-
fore, we can determine what filtration to use
to fulfill this condition. Evidently there is
more than one choice. However, not all pos-
sible combinations of primary and secondary
filter which could be used are equally eco-
nomical. In the first place, it will be seen
that in no case is the absorption curve a
straight line when the ionization is over 6%.
This means that at best we can use for deep
therapy only 6% of the radiation emitted by
the bare glass tube. At this point it is inter-
esting to note that when tissue is used as the
absorber, the absorption is not exponential
up to a thickness of about 5 cm. Accordingly
if tissue or some organic substance of about
the same density were used for deep therapy,
a thickness of five or more centimeters would
be necessarv. Aside from the inconvenience

Absorption of Radium Radiation by Tissues

221

^0-

80 -

7"-

CURVES SHOWING ABSORPTION BY TISSUE OF
RADIATION FILTERED THROUGH BRASS

A Tissue alone

B 0.48 mm. Brass plus Tissue

C C.96 mm. Brass plus Tissue

D I 92 mm. Brass plus Tissue

E 3.04 mm. Brass plus Tissue

F Brass alone

Jsl.

I.L.

Jii.

i.L

1-5.

l-iL

Absorption of Radium Radiation by Tissues

of such a bulky filter, its use would entail an
unnecessary loss of radiation, because the
ionization produced by radiation filtered
through 5 cm. of tissue is 4.8%, while other
filters can give 6%. The reason for this is
that the diminution of the intensity of the
beam of radiation passing through a filter of
low atomic weight is primarily due to the
scattering of the radiation and not to true
absorption. Since the scattering by sub-
stances of low atomic weight is not very dif-
ferent for the different qualities of radiation,
the softer components of the beam of radia-
tion are not effectively eliminated in this
manner. Hence substances of low atomic
weight are not efficient filters,^ and the large
thickness recjuired to obtain the proper filtra-
tion causes undue scattering and absorption
of the penetrating radiation as well. This
brings out the desirability of using a metalic
filter. In general an additional filter of low
atomic weight is necessary to remove the
soft, secondary radiation of the metal. '^

The straight line parts of the curves of
Figures 3 and 4 are not parallel, but nearly
so. This means that filtration by different
thicknesses of the same metal changes the
penetrating power of the radiation some-
what. The magnitude of this change can be
seen from Table II, in the column for the
percentage of radiation absorbed by i cm. of
tissue. Thus, when the filter is ^ mm. of
brass, i cm. of tissue absorbs 7-7%, while
for 3 mm. of lead filtration the correspond-
ing value is 7.1 %. The radiation in the latter
case is more penetrating than the former. If
we increase the filtration considerably, the
penetrating power of the radiation can be
increased further.

In deep therapy there are two factors
which affect the amount of radiation which
reaches the tumor: the distance of the tumor
from the source of radiation- and the absorp-
tion of part of the radiation Ijy the interven-
ing layers of tissue. For any one set of con-
ditions, that is, distance of source from skin,
strength and distribution of source, and
depth of tumor, the quantity of radiation
which reaches the tumor depends on the pen-

etrating power of the radiation. The more
penetrating the radiation, the more of it will
reach the tumor. From this point of view,
therefore, it is obvious that it is desirable to
use the most penetrating radiation available.
This, however, is not the only consideration
involved in the problem. When radium is
used as the source of radiation, the only
means of obtaining a more penetrating radia-
tion is the use of a heavier filter, which of
necessity entails a decrease in the amount of
the available radiation. Furthermore, the
limiting factor in deep therapy is the effect
on the skin, since this is always greater than
in deep layers, neglecting any difference in
susceptibility which may exist between dif-
ferent tissues. Therefore it is important to
know what fraction of the radiation which
falls on the skin reaches the tumor. The
maximum value of this fraction is deter-
mined by the relative distances of the skin
and tumor from the source. Thus, if a point
source of radiation is placed at a distance of
3 cm. from the skin, and the farthest point
of the tumor is 3 cm. below the skin, (i.e., 6
cm. from the source) the most that the tu-
mor can receive is ^ as much as the skin.
This is on the assumption, which can never
be realized in practice, that the 3 cm. of tis-
sue intervening between the source and the
back of the tumor do not absorb any radia-
tion at all. Allowing for the absorption by
the tissue of radiation filtered through i mm.
of brass plus 8 mm. of rubber, we find that
the distant parts of the tumor receive 19.9%
of the radiation which falls on the skin, in-
stead of 25%. Using a filter of 3 mm. of lead
plus 7 mm. of rubber, the radiation at the
back of the tumor will increase from 19.9%
to 20.2%; that is, it will be 1.5% greater
for the same skin dose. This, however, will
decrease the intensity of the source of radia-
tion from 6.3% to 4.6%, or 27%, so that in
order to obtain the same skin dose using the
same amount of radium the duration of
the application must be prolonged 27%. The
advantage of getting 1.5% more radiation
in the tumor may offset the disadvantage of
a longer exposure, but. is there any other

Absorption of Radium Radiation by Tissues

~^o

224

Absorption of Radium Radiation by Tissues

way of accomplishing the same purpose with
greater economy? The relative amount of
radiation which reaches the tumor can be
increased also by placing the radium at a
greater distance from the skin while still
using the same filtration as in the first case.
Let us determine what this distance should
be in order to have 1.5% more radiation in
the tumor, that is, 20.2% of the amount
reaching the skin. Figure 5 shows the nota-
tion used below. The percentage of the skin
radiation which reaches the tumor is given

by the expression

lOOX"

■j X e-ytid. If this
0.0755, then

(x+z)^

is to be 20.2% when z = 3, )u

100 X-
7^^j—pX 0.797=20.2, whence x=3. 1 cm.

Therefore in this particular case an increase
of 0.1 cm. in the distance of the applicator is
sufficient to increase the tumor radiation
1.5%. To get the same skin dose the time
will now have to be increased in the ratio

(3-1)'

— -^ — =1.068, or less than 7%. Since in

using a ^higher filtration we found that the
time of application had to be increased 2"/%,
it is evident that the same result can be ob-
tained more economically by increasing the
distance. This example has been worked out
to illustrate this point. In practice, however,
an increase of 1.5% would be insignificant.
If we had considered the dose at a much
greater depth, the effect of a higher filtration
would have been larger, and the adjustment
in distance to get the same result would have
been necessary.

From the law of conservation of energy
it follows that, in order to affect the tissue,
some of the radiant energy traversing the
tissue must be absorbed by it. In fact, as
stated in the first part of the paper, there is
considerable evidence tending to show that
the physiological effect is dependent on the
amount of radiation absorbed by the tissue.
From this point of view, then, there is an
advantage in using radiation which is more
easily absorbed by tissue, provided we can
obtain the same ratio between the skin dose

and the tumor dose, by properly adjusting
the distance of the applicator. This simply
means that for the same total amount of
radiation falling on the skin a given physio-
logical effect can be obtained in a shorter
time in the case of the softer radiation. As,
however, the time element does not influence
the ratio between the skin dose and the deep
dose, it will be seen that the fact that tissue
absorbs more of the softer radiation does not
tend to increase the deep dose in comparison
to the skin dose. On the contrary, it is very
effective in decreasing the amount of radia-
tion which reaches the deeper layers of
tissue.*

In the light of what has just been said, it
is reasonable to ask : Can we obtain the same
relative dose of radiation at a certain depth
of tissue by using .ar-rays and placing the
tube at a greater distance from the skin ? The
answer to this question depends entirely on
the quality of the ,r-radiation available. In
the example given above it will be seen that
the controlling element was the "dispersion"
of the radiation and not the absorption. Con-
sidering the effect of distance alone, the dose
at a depth of 3 cm. was only 25% of the
dose on the skin, that is, there was a loss of
75%. On the other hand, the loss due to
absorption by 3 cm. of tissue was 20.3%,
which is small in comparison. In the case of
.r-rays the conditions are reversed. The tar-
get-skin distance probably, would not be less
than 20 cm. Then for a tissue depth of 3 cm.
the dose, neglecting absorption, would be

7 — V2" ^^ 75-7% of the skin dose. To get

the same percentage of the radiation as in
the previous case, that is 20%, we can now
afford to lose 55.7% through absorption.
Using the same equation as before we can

* In working out the above example no account
was taken of the above mentioned effect of the
quality of the radiation on the time of irradiation.
This is justified because the quality of the radiation
in the two cases was only slightly different, and under
these conditions the ionization method of obtaining
the absorption curves used in solving the problem
automatically compensates for the difference in the
absorption of the two types of radiation.

Absorption of Radium Radiation by Tissues

225

determine the degree of penetration which
the .r-rays must have in order to get at a
depth of 3 cm., 20% of the radiation falling
on the skin.

X = 20, z

100 X 20-

e-3/x = 20. There-

Table I gives the relative amounts of radia-
tion reaching different tissue depths for dif-
ferent conditions of application.

A comparison of columns F, B, and D
shows that when the distance of application

(20 + 3)^

fore jti = 0.443. That is, when a homogen-
0443

is increased from _
tion at a depth of

to 20 cm., the radia-
3 cm. increases from

eous ,r-radiation is

5.87 times less

0.0775

penetrating than the gamma rays, and the
target is at a distance of 20 cm. from the
skin, we get at a depth of 3 cm. of tissue
20% of the radiation falling on the skin.
If, however, for the purpose of comparison,
we place our radium source at a distance of
20 cm. then the dose at a depth of 3 cm. is
60% of the skin dose instead of 20%.* In
practice it is desirable to have as little differ-
ence as possible between the skin dose and
the tumor dose. This condition would obtain
if the source were placed at a great distance
from the skin ; that is, for parallel rays. Then
the only factor which limits the radiation at
any depth is the absorption. If parallel radia-
tion were used, we would get at a depth of
3 cm. 79.7% of a skin dose in the case of
gamma rays, and 26.4% in the case of .^--rays
six times less penetrating than gamma rays.f

source.

Fig. 5. Diagram showing relative positions of tumor,
skin and source of radiation.

19.9% to 60.2%, while the theoretical maxi-
mum for infinite distance is 79.7%. From
this we see that when the distance of appli-
cation is great in comparison to the tissue
depth, further increase in the distance is of
little help in increasing the tumor dose. The
values in columns F and G show that when

TABLE I

Tissue

Source 20 cm. from skin

Source at infinite distance

Ra. 3 cm.

Target 20 cm.

depth cm.

from skin

from skin
X-rays

Gamma rays

X-rays

Gamma rays

X-rays

Gamma rays

/A = 0.0755

(i — 0.443

^ = 0.0755

fx — 0.443

,x = 0.0755

fx. = 0.443

100

84.2

58.4

92.8

64.3

52.2

58.4

71.0

340

85.9

41. 1

31-0

34-0

60.2

20.0

79-7

26.4

19.9

20.0

51-2

11.8

73-9

17.0

13-6

11.8

43-8

7.0

68.5

10.9

9.6

7.0

i^-i

2.5

58.9

4-5

5-3

2.5

* Whence we see the advantage of using a more
penetrating radiation when the conditions of appli-
cation are the same.

t The filtered jr-radiation used at the present time
for deep therapy is about twice as penetrating as the
.;r-rays of this example, and less than one third as
penetrating as the gamma radiation of radium when
the filter is 2 mm. of brass.

the distances are adjusted so as to get the
same skin dose and the same tumor dose at a
depth of 3 cm., using radiation of different
degrees of hardness, the doses are not the
same at any other tissue depth, and especially
at greater depths than the one for which the

226

Absorption of Radium Radiation by Tissues

doses are the same (3 cm.). The more pene-
trating radiation "wins out." This may be
an advantage or a disadvantage according to
the conditions.*

There are some limitations to the applica-
bihty of the results so far obtained which
should be mentioned at this point. The most
important is the effect of the scattered and
secondary radiation on the tumor dose. The
amount of radiation which reaches the tumor
may be divided into two parts ( i ) that which
travels in a straight line from the source to
the tumor, and (2) that which reaches the
tumor in a roundabout way. The latter is
composed of (a) the radiation which is scat-
tered, that is, deflected from its straight line
path by the tissue surrounding the tumor,
and (b) the secondary radiation which is set
up in the tumor by the primary beam. The
relative amounts of (i) and (2) depend
on the depth of the tumor, the latter becom-
ing more important as the depth increases.
The method of measurement adopted for
these experiments enables us to measure only
the amount of the primary radiation which
reaches a certain depth of tissue. The data
thus obtained, therefore, enable us to calcu-
late the minimum amount of radiation which
reaches a given tumor under the conditions
of application. The upper limit is obtained
by neglecting the absorption of radiation by
tissue and calculating the effect of distance
alone. The actual radiation which reaches a
certain depth of tissue is between these two
limits. It can be determined by using a differ-
ent experimental arrangement, which we
hope to do in the near future.

Another limitation is imposed by the use

* From the preceding discussion we see that, within
certain limits, we can get the same amount of radia-
tion at a given depth of tissue for the same skin
dose by using radiation of distinctly different pene-
trating power, provided the distance of application
is suitably chosen. Whether we would get the same
physiological effect is a different matter, and one
which cannot be determined by physical experiments
alone. The question really is whether the physio-
logical effect is independent of the quality of the
radiation. At the present time this is not definitely
known, but the scanty evidence available in the litera-
ture seems to support the conclusion that within cer-
tain hmits it is independent of the quality.

of a metallic ionization chamber, as discussed
in the first part of the paper. This, however,
influences our results only when the quality
of the radiation whose absorption we are
measuring is changed appreciably in passing
through the tissue used as the absorber. As
this does not occur in the case of the pene-
trating radiation used in deep therapy, no
error is introduced in using, for this purpose,
the data here obtained. But it is not possible
to use these absorption curves to determine
accurately the beta ray dose for the skin
from a knowledge of the gamma ray dose,
or vice versa. For instance, if the ionization
value of the bare emanation tube is 100%,
and for a tube screened by 2 mm. of brass it
is 6.7% (Figure 3, curve D), it is not cor-
rect to assume that, other conditions being
the same, the time of exposure to produce
the same superficial effect in the case of the

100
screened tube would be -^ — or i s times

6.7 -^

longer than in the case of the bare tube. The
two have to be determined independently by
physiological experimentation. The curves
enable us to make a first approximation to
the doses for various qualities of radiation ;
the correct values can be obtained by actual
trial.

There is another point which requires
further elucidation, that is, the significance
of the ionization values given in the charts.
A given quantity of radium emits radiation
in all directions. The amount of radiant
energy which passes through a surface
of unit area perpendicular to the line of
propagation 'represents the intensity of the
radiation at this surface, independently of
the quality of the radiation under considera-
tion. But if we attempted to measure this in-
tensity using ordinary ionization methods,
the value we would obtain would depend to
a great extent on the quality of the radiation.
For instance, for beta rays, we could have
an ionization chamber in which the gas
would absorb all the radiation entering it,
but for gamma rays only a fraction of the
total radiation would be absorbed. In the
latter case, then, we would not be measuring

Absorption of Radium Radiation by Tissues

227

the intensity of the radiation. To take the
extreme case, if there were radiation which
would not be absorbed at all by matter, then,
however strong the source might be, we
would never detect it by the means at our
disposal, or, in fact, by any other means, if
the law of conservation of energy is to hold.
For this reason, when we are dealing with
radiation of different qualities, and espe-
cially of different types, as the beta and
gamma rays, we cannot speak of their rela-
tive intensities. Therefore the values on the
charts are given in percentages of the total
ionization produced when the emanation tube
has no additional filtration, and they do not
represent the intensity of radiation after
passing through a filter or tissue or both, but
the intensity of ionization which it produces.
Accordingly it is not strictly correct to say
that the radiation of an emanation tube is de-
creased from 100% tQ 6% by a filter of 2
mm. of brass plus 10 mm. of tissue. The
radiation, considering the energy which is
associated with it, is more than 6%, but this
figure indicates the availability of its energy
in affecting matter. For our purposes this
is not a disadvantage, but an advantage. We
are not concerned with the amount of radia-
tion passing through tissue, but with the
amount which is capable of influencing vital
processes. When the quality of the radiation
is not materially changed by the absorber, it
is correct to say that the intensity of the
radiation is decreased a certain percentage by
the absorber. In such cases the factor of
proportionality between the energy of the
radiation and the amount absorbed remains
the same. In addition to the effect of the
material of the ionization chamber on the
percentage values given for the different
thicknesses of absorber, it should be borne
in mind that the numerical values de-
pend on the quality of the radiation which
is taken as producing 100% ionization. This
in turn depends on the wall thickness of the
glass tube containing the emanation, which,
however, does not affect the relative position
of the curves.

In Table II, column 5, are given the co-

efficients of absorption for different metals
and different tissues. Little need be added to
what has already been said about the absorp-
tion by metals. The three coefficients given
for lead indicate the change in the quality of
the gamma radiation as the thickness of lead
increases. In column 4 are shown the range
of thicknesses for which the coefficients of
absorption were determined. Column 6
shows the half value thickness, that is, the
thickness of absorbing material needed to
reduce the radiation to one half its initial
value. The density (column 7) and the co-
efficient of absorption divided by the density
(the so-called mass absorption coefficient,
column 8) are given to show how the ab-
sorption varies with the density of the ab-
sorber. In column 9 are found the percent-
ages of the radiation absorbed per millimeter
of filter corresponding to the absorption
coefficients given.

The values in the second part of the table
were determined from the curves of Figures

3 and 4. They show the relative change in
the absorption of radiation filtered through
various thicknesses of lead and brass by beef
muscle hardened in 10% formalin. It will
be seen that from a filter of ^ mm. of brass
to one of 3 mm. of lead the change is
0.0765 - 0.0709

00765 =7-3%- The mass absorp-
tion coefficients have no special significance
in this case, and they are not included in the
table. It should be noted that the values in
column 9 are given for one centimeter of
tissue, and not for one millimeter, as in the
case of metals.

The values in the third part of the table
indicate the relative absorption of the radia-
tion filtered through 1.92 mm. of brass by
different tissues. For these experiments fresh
organs were obtained. They were cut into as
nearly parallel slices as possible, and absorp-
tion curves similar to those of Figures 3 and

4 were determined. The experimental work
for fresh liver, spleen, muscle, brain, suet,
and lung, as well as the formalined muscle,
was done continuously, with the same
emanation tube in the same position from

228

Absorption of Radium Radiation by Tissues

beginning to end. To make sure that the ex-
perimental conditions remained the same
throughout, the absorption curve for pure
gum rubber was determined at intervals, and
used as a check. This also enabled us to in-
clude in the table some data obtained on
previous occasions. The logarithms of the
ionization values for different thicknesses
of tissue were plotted to a very large scale
and average straight lines drawn, as in the
case of Figures 3 and 4. The coefficients of
absorption were then determined by reading
off two values from the straight lines.

From column 9 we see that the amount of
radiation filtered through 1.92 mm. of brass
which is absorbed by one centimeter of tissue
is not very different for the different kinds
of tissue. The two conspicuous exceptions
are solid bone, which absorbs almost twice
as much radiation as the average, and lung,
which absorbs a little more than half as much
as the average.

It is often assumed that the absorption of
gamma rays is proportional to the density of
the absorber. The table enables us to test the
accuracy of this assumption. If the absorp-
tion were proportional to the density, then
all the values in column 8 for the same
quality of radiation would be the same. Evi-
dently this is not the case. From physical
experiments we know that the mass absorp-
tion coefficient {i^/p) is the same for sub-
stances which have essentially the game
chemical composition. As this condition is
practically fulfilled by all the soft tissues
given in the table, we should expect the
values of ij^/p to be substantially the same.
If we stop to analyze the results we find that,
within the limits of experimental error this
is the case. For lung tissue the value of /x/p
is considerably lower than the average. The
discrepancy, however, can be attributed to
the numerous air spaces in this kind of
tissue, which are included in the measure-
ment of thickness, but are not, included in the
determination of the density, since they do
not contribute to the volume of the piece of
tissue measured by the amount of water dis-
placed. The calculated density, consquently,

was too high, and the mass absorption co-
efficient too low. The smaller difference in
the value of /t-t/p for brain may be accounted
for in the same way.

The explanation of the low value of /w/p
for solid bone is based on the results of many
physical experiments, which show that the
mass absorption coefficient is lower for sub-
stances of medium atomic weight than for
substances of very low or very high atomic
weights." Thus in Table II it is seen that the
value for soft tissues, which have essentially
the same composition and contain only ele-
ments of low atomic weight, are higher than
for aluminum or brass, but lower than the
first value for lead, which has a very high
atomic weight. (The other values for lead
are not comparable with the tissue values
because the quality of the radiation in the
two cases is quite different.) Solid bone,
which contains considerable calcium, there-
fore, approaches aluminum in absorbing
power, and for this reason the value of m/p
is lower than for soft tissues. "Porous
bone," as used in this experiment, consisted
of a bony structure having its interstices
filled with soft tissue. Theoretically, then, the
value of li-fp should be higher than for solid
bone and lower than for soft tissue. Experi-
mentally it is found that this is the case.

Considering the methods of determining
the density of soft tissues, it is reasonable to
conclude that, within the limits of experi-
mental error, the mass absorption coefficients
for soft tissues are equal. For practical pur-
poses, therefore, we may say that in this case
the absorption of gamma rays filtered by
1.92 mm. of brass is proportional to the
density of the tissue. This is not the case
when tissue is compared with aluminum and
brass. For instance, if we know the coeffici-
ent of absorption for aluminum and we cal-
culate its value for tissue of density 1.03,
in the ratio of the densities, we get /* =

O.I I X "^^ = 0-0413. But the value experi-
2.74

mentally determined is 0.0694, which is 68%

higher than the calculated value. On the

other hand, the absorption of gamma rays by

Absorption of Radium Radiation by Tissues

229

tissue when calculated from the absorption

by pure gum rubber, is correct for practical

1.03
purposes. (0.066 X = 0.070 instead of

0.069.) Ii^ the case of solid bone the absorp-
tion per centimeter is greater than for alumi-
num, in spite of the fact that the density of
the latter (1.74) is considerably greater than
the density of bone (2.01). In radiotherapy
it is often assumed that the absorbing power

of one centimeter of tissue is the same as
that of one millimeter of aluminum. Prob-
ably this is true for .r-rays of a certain
quality, but it is very far from the truth in
the case of gamma rays.

With the exception of solid bone the tissue
which absorbs most radiation absorbs 7.5%
per centimeter of thickness. Therefore, if in
calculating the amount of radiation which
reaches a certain depth, we take the value of

TABLE II

I
Filter

Thickness
mm.

Absorber

Range

mm.

5
Coef. of
Abs. cm.-^

H. V. T.*

cm.

7
Density

8 { 9

fi/f) % abs.

cm. -1 per mm.

Aluminum
Brass

Aluminum

6-22

O.II

6.3

2.74

0.0402

I.I

Brass

2-22

0.35

1.98

8.26

0.0424 1 3-5

Lead
Lead

Lead

2-5

1. 01

0.686

11-34

0.0892 j 1 0.1

Lead

5-10

0.80

0.866
1.05

11-34

0.0705

8.0

Lead
Lead

Lead

10-15
15-22

0.66

11-34

0.0582

6.6

Lead

0.58

1.20

11-34

0.05 1 1

5-8

% abs.
per cm.

Tissue

5.00

Formalin
Beef Muscle
Formalin
Beef Muscle

50-60
10-70

0.0815

8.50

8.2

Brass

0.48

0.0765

9.06

7-7

Brass

0.96

Formalin
Beef Muscle

10-70

0.0755

9.18

7-6

Brass

1.92

Formalin
Beef Muscle
Formalin
Beef Muscle

10-70

0.0752

9.22
9.22

1.056

0.0713

7-5

Brass
Lead

3-04

10-70

0.0752

7-5

0.4s

Formalin
Beef Muscle
Formalin
Beef Muscle
Formalin
Beef Muscle
FoiTTialin
Beef Muscle

10-70

0.0752

9.22

7-5

Lead

I.O

10-70
10-70

0.0736

9.42

7-4

Lead

2.0
30

0.0726

9-54

7-?,

Lead

10-70

0.0709

9-77

7-1

Brass

1.92

Solid Bone

3-20

0.13

5-5

2.01

0.063

13-

7-5

Brass
Brass

1.92
1.92

Porous Bone

20-100

0.075

9-3

I-I5

0.065

Liver

Spleen

Muscle

20-90

0.074

9.4

1.06

0.070

7-4

Brass

1.92

20-100

0.073

9-5

1.05

0.070

7-Z

Brass

1.92
1.92

20-100

0.069

lO.O

1.03

0.067

6.9

Brass

Brain

20-100

0.066

10.6

1.03

0.064

6.6

Brass

1.92

Suet

20-100

0.065

10.7

0.94

0.069

6.5

Brass

1.92

Lung

20-70

0.045

iS-5

0.78

0.057

4-5

Brass

1.92

Rubber

10-50

0.066

10.5

0.97

0.068

6.6

Brass

1.92

Formalin
Beef

20-70

0.075

9.2

1.06

0.071

7-5

*Half Value Thickness

230

Absorption of Radium Radiation by Tissues

0.075 for the absorption coefficient, we are
sure to be on the safe side. It will be seen
also for deep radium therapy that the effect
of intervening bones on the tumor dose must
be small, because the actual thickness of
solid bone is small in comparison to the
thickness of soft tissues, and the absorption
by porous bone is only slightly greater than
that of soft tissues. This, however, is not
true in the case of .r-rays, and especially of
soft .:r-rays. A convincing proof of this
statement is afforded by .r-ray photographs
taken with soft and very hard rays. As for
the absorption by human tissue compared to
beef tissue, it may be said that in general the
former absorbs a little less radiation than the
latter. The difference, however, is practically
negligible when the same kind of tissue or
organ is considered in the two cases. One
notable exception is fat, the absorption by
human fat being considerably less than the
absorption by suet. But in this case the den-
sities are also quite different. The absorption
by the fat under the human skin is about
two thirds that of an equal layer of the skin
proper.

SUMMARY

1. The apparatus used, consisting of a
gold leaf electroscope and conical ionization
chamber, and the experimental procedure are
described in detail.

2. The most important limitations im-
posed by the experimental method adopted
are discussed. They are due to:

(a) Use of a metal ionization chamber.

(b) Use of a gas as the absorbing medium

in the ionization chamber.

radiation produced in tissue.

(d) Inability to reproduce in the physical

laboratory physiological conditions.

3. The absorption curves for aluminum,
brass, and lead are given. From these we see
that:

(a) As the filter increases the transition
from soft to hard radiation is quite
sharp.

(b) Beyond a thickness of filter of a few

millimeters in the case of aluminium
and brass the absorption is exponen-
tial (I = lo e-/Ad). In the case of lead
it is not exponential in the range of
thickness used.

thickness of metal is sufficient to give
a radiation which is absorbed expo-
nentially by metals of medium or low
atomic weight. The radiation, how-
ever, is not strictly homogeneous, as
indicated by the lead absorption
curve.

4. The criterion for the quality of radia-
tion to be used in deep therapy being the ex-
ponential absorption of the radiation by tis-
sue, from Figures 3 and 4 we see that:

(a) A metal should be used as the primary

filter.

(b) A secondary filter, composed of light

elements like tissue, should be used to
remove the soft, secondary radiation
of the metal.

mary and secondary filters suitable
for deep therapy.

(d) Beyond a certain point additional fil-

tration, while increasing the penetrat-
ing power of the radiation slightly,
decreases the intensity of the radia-
tion considerably. '

5. In deep therapy the limiting factor is
the effect on the skin. Therefore it is im-
portant to know what fraction of the skin
radiation reaches a given depth of tissue.
The value of this fraction can be varied
within limits by varying the distance of the
applicator from the skin, or the filtration,
(a) An example is worked out to show that

in the case of gamma rays it is more
economical to increase the percentage
of the skin radiation which reaches a
deep tumor by increasing the distance
of the applicator than by increasing
the filtration.

Absorption of Radium Radiation by Tissues

231

(b) A second example shows that, using

two sources of radiation of distinctly
different penetrating power, we can
get the same percentage of a skin
dose at a certain depth of tissue in
either case by choosing the distance
of application properly.

the applicator is large in comparison
to the tumor depth, the penerating
power of the radiation has the greater
influence on the tumor dose. (This is
the case of .t--rays.) On the other
hand, when the distance of applica-
tion is about the same as the tumor
depth, and the radiation is very pene-
trating, the distance has the greater
influence on the tumor dose. (This is
the case of radium therapy.)

(d) The table shows, also, that when the

distances are adjusted so as to get the
same skin dose and the same dose at
a depth of three centimeters, using
radiation of different degrees of
hardness, the doses are not the same
at any other tissue depth, and es-
pecially at greater depths than the
one for which the doses are the same.

6. The coefficient of absorption is the im-
portant factor which identifies radiation. The
numerical value depends on the quality of
the radiation and on the nature of the ab-
sorber. From Table II we see that:

(a) When the same tissue is used as an ab-

sorber and the filtration of radium
rays is varied in steps from 0.48 mm.
of brass to 3 mm. of lead, the coeffi-
cient of absorption gradually de-
creases from 0.0765 to 0.0709. But
while the penetrating power of the
radiation is increased 7.3% by the
additional filtration, the available ra-
diation is decreased 65%.

(b) The same radiation (1.92 mm. brass

filter) is absorbed to a different ex-
tent by different tissues. For soft tis-
sues the coefficient of absorption is
proportional to the density of the
tissue.

organs (except lung tissue, fat, and
solid bone) is nearly the same. There-
fore if we take 0.075 ^^r the value
of the coefficient of absorption of
gamma radiation filtered through
1.92 mm. of brass, we are sure to be
on the safe side in any calculation we
may make for practical use. Corre-
sponding to this value of the absorp-
tion coefficient, the thickness of tis-
sue necessary to absorb one half of
the radiation is gj4 centimeters. As a
round figure, easy to remember, we
may take the half value thickness of
human muscle tissue for gamma rays
to be ten centimeters.

(d) The presence of bone in the path of the

radiation is of no great consequence
in regard to the amount of gamma
radiation which reaches the tumor be-
yond it. The only part of the bone
which absorbs considerably more
than muscle is the solid part. But in
any practical case this makes up a
small fraction of the total thickness
traversed by the radiation. In the case
of .t'-rays bone plays a more import-
ant part.

7. The results obtained from the experi-
ments described in this paper can be used for
the solution of problems in radium therapy,
subject to the following limitations:

(a) The calculated amount of radiation

reaching any given tissue depth is al-
ways the miniinmn amount which
will reach this depth under the condi-
tions of application.

(b) Skin doses of beta and gamma radia-

tion are not to be compared accord-
ing to the ionization values given in
Figures 3 and 4. They must be de-
termined independently by physio-
logical experiments.

In conclusion the author wishes to ac-
knowledge his indebtedness to Mrs. E. H.
Quimby for her assistance in the preparation
of the material for this paper.

232

The Newer Roentgen Therapy in Cancer

REFERENCES

SoDDY AXD RussEL. Philosophical Mag., 1901, xviii,

620.
Rutherford and Richardson. Philosophical Mag..

1913, XXV, 722.
Rutherford. Radioactive Substances and Their

Radiations, 2 ed., 262.
TuoMiKOSKi. Physikalische Ztschr., 1909, x, 2>72.

5. Barkla and Miss White. Philosophical Mag.,

igi/, xxxiv, 202.
Hull and Rice. Phys. Rev., September, 1916.

6. SoDDY. The Chemistry of the Radio-Elements, Part

II, page 3.

7. QuiMBY. Am. J. Roentgenol., 1920, vii, 492.

8. Rutherford. Philosophical Mag., 1917, xxxiv, 153.

9. RusSEL AND SoDDY. Philosophical Mag., 1911, xxi,

130.

PERSONAL EXPERIENCE WITH THE APPLICATION OF THE
NEWER ROENTGEN THERAPY IN CANCER*

By M. J. SITTENFIELD, M.D.

NEW YORK CITY

^ I ''HE ideal that every therapy attempts to
■*■ attain is a complete inhibition and
neutralization of the disease, and if possible
the maintenance of normal function. Unfor-
tunately excision of a cancer does not pre-
vent further invasion, nor immunize against
it, nor does it maintain the functions of the
tissue affected. So it is easily conceivable
why radiotherapy, even with our former
limited knowledge, played such an important
part in the treatment of cancer. The fact that
recent advances in the technique of radio-
therapy have been accomplished abroad
makes it apparent that the older methods
were found wanting. It is almost needless to
say that insufficient penetration of hard rays
to the deeper tissues was one of the short-
comings; another was the lack of measure-
ments for practical purposes, and also the
lack of knowledge of the exact dosage neces-
sary to influence a carcinoma, a sarcoma or
ovary.

Some of these obstacles were overcome by
the construction of more powerful appara-
tus, and also tubes to tolerate higher inten-
sities. The electroscope and iontoquantimeter
furnished means of measurement for prac-
tical purposes, and with these, the determina-
tion of dosage for the destruction of car-
cinoma and sarcoma were made possible.
Apparatus, tubes and technique have been
described elsewhere, and need not be men-
tioned here,

*Read at the Midwinter Meeting of the Eastern Section of

Tanuarv 2

The application of the newer methods of
roentgen therapy has led to more gratifying
results in the treatment of cancer. Since my
return from abroad in the middle of Sep-
tember, owing to the delay in shipping the
German apparatus, this improved technique
as far as it is applicable to my own appara-
tus, has been made use of. The following
case report is, of course, a preliminary one,
and only one of a type has been selected.

One of the first cases selected for this
newer therapy was a patient with an inoper-
able carcinoma of the cervix. She had re-
ceived a radium treatment three and a half
months previous, with no evident arrest of
the disease. The malignant process con-
tinued, so that when she first came to me, her
hemoglobin was 40 per cent, and to all
appearances, she was in a beginning state of
cachexia. Desirous of trying out the newer
technique, she was subjected to the follow-
ing treatment: a two hour radiation dose
on four consecutive days was administered,
instead of one session of eight hours, as in
Bumm's Clinic. The focal distance used was
50 cm., and the portals of entry 15 by 18
cm. The rays were filtered through 0.5 mm.
of zinc, plus I mm. of aluminum. In addition
50 mg. of radium element were introduced
into the cervix and left there for fifty hours.
My aim was to administer what the Ger-
mans call a full cancer dose at one session.
The reaction was not as severe as those I

The American Roentgen Ray Society, Atlantic Citj', N. J.,

?, 29, T92T.

The Newer Roentgen Therapy in Cancer

233

saw in Germany when the entire treatment
was given in one day. The patient gained
five pounds in weight within the first week,
pain disappeared entirely, and she is at pres-
ent going about, engaged in her usual activi-
ties, free from any clinical manifestations
of the disease. A month ago examination of
the cervix showed it to be entirely fibrosed.

Another patient was referred for radia-
tion for recurrent carcinoma in the axilla
after radical excision of a carcinoma of the
breast. Female, sixty years old, was operated
upon for carcinoma of the breast a year and
a half ago. Six months later a tumor re-
curred in the axilla; it was removed again,
only to recur within the year. The recur-
rence, when she reported to me, was the size
of half an orange, it was a fluctuating mass
of broken-down, necrotic tissue. She suffered
much pain, and had to be constantly under
the influence of opiates. All in all, she was
in pretty bad shape. She also received four
radiation doses of two hours each on con-
secutive days. A dose was directed from
front of axilla, one posteriorly into axilla,
one from above the shoulder joint, and one
from below into the axilla. The focal dis-
tance was 50 cm., the filter zinc plus alum-
inum, and the portals of entry 15 by 18 cm.
Four days after completion of the roentgen
treatment, 3,000 mg. hours of radium ele-
ment were placed in the axilla over four
areas. A week later the tumor had disap-
peared entirely, she was free from discom-
fort, and had left off all narcotics.

In another patient a carcinoma of the
breast had recurred over the anterior region
of the sternum. The patient was operated
upon two and a half years ago for carcinoma
of the breast at Mt. Sinai Hospital, had a
stormy convalescence, developed erysipelas
with abscesses, and had to stay in the hos-
pital for three months. In October last a re-
currence of about 12 by 15 cm., the size of
the palm of my hand, developed over the
sternum extending to the anterior axillary
border. Two radiation doses of four hours
each, with 70 cm. focal distances, portals of
entry 15 by 18 cm., zinc and aluminum fil-

ters, were administered. A week later the
tumor had receded by half, and in another
week the entire tumefaction had disappeared.
In this case, about seven weeks ago, a tumor
the size of a large lemon made its appearance
in the other breast. The surgeon again re-
ferred her for radiation, considering her a
bad risk for surgical intervention. A full
cancer radiation dose was administered, and
the tumor has since receded.

These reports are of course only prelimin-
ary; the end results may be such, perhaps,
as to cause a modification. Furthermore the
response in all cases may not be as striking
as in these. It is obvious, however, that more
intensive radiation than heretofore must be
administered along the lines of modern tech-
nique. The dosage in this newer technique
comprises a more thorough understanding of
the biological and physical properties of the
rays as they are emitted from the tube, and
of the accompanying secondary radiation.
The quality of ray, in particular, is one of
the most important factors, and of equal
importance are the substance and amount of
filtration used, the focal distance, and the
size of the portals of entry. The propor-
tionate relationship between the radiation
energy at the surface of the body, and that
of the lesion in the deeper tissues, is called
the dosage quotient. This dosage will be most
favorably effective in the deeper tissues
when we increase the distance of the radia-
tion source, notwithstanding the fact that
an increase in the focal distance necessarily
increases the time of obtaining a skin ery-
thema dose.

It is well known that with 0.5 or i mm. of
copper or zinc as a filter, a considerable
amount of the energy emitted from the tube
is lost. This loss is more than compensated
for by the fact that radiation through 0.5 or
I mm. of copper or zinc produces a more
favorable absorption coefficient. In other
words rays from this point on will show very
little qualitative change, and additional fil-
tration would serve no further purpose.

In addition to the primary rays, the
scattered secondary rays materially aid the

234

The Newer Roentgen Therapy in Cancer

dosage quotient. For instance, it has been
worked out by Friedrich and others, that
with 50 cm. focal distance, and a 10 mm.
aluminum filter, the primary radiation
energy under 6 cm. of tissue would be 22
per cent that of the surface dose ; in reality,
though, it is increased to 51 per cent by the
scattered secondary rays.

CHART I

Estimated Actual

Depth Primary % with

Focal under Dosage Secondary

Filter Distance Surface % Rays

10 mm. Alimi.

50 cm.

6 cm.

22. %

51- %

50 cm.

8 cm.

13-8%

42. %

50 cm.

10 cm.

8.4%

31- %

I mm. Copper

50 cm.

6 cm.

25. %

67.5%

SO cm.

8 cm.

17. %

54- %

50 cm.

10 cm.

10. %

44- %

Aside from this increase in the amount of
radiation available in the deeper tissues
through the proper filtration, the size of the
portals of entry must be given consideration.
For example, under 10 cm. of tissue, with
a portal of entry of 1.5 by 2 cm., the dose
is 9 per cent of that received on the surface ;
with a portal of 6 by 8 cm., however, the
amount is increased to 28 per cent, and with
portals of 10 by 15 cm., to 35 per cent, and
so on. In other words, the larger the portal
of entry, the more favorable is the dosage
quotient, up to a point of 20 by 20 cm. Any
increase in size over this seems to bring no
appreciable gain; that is, the intensity of
the ray diminishes by dispersion the smaller
the portal of entry, and increases in percent-
age the larger the portal of entry.

CHART H

Dosage Quotient in the Deeper Tissue

(Focal Distance 50 cm.)

Portal of Under 10 cm. Under 3 cm.

Entry Tissue Tissue

1.5 X 2 cm.
6x8 cm.

10 X 15 cm.

28%

35%

47%
66%

77%

Chaoul, of Sauerbruch's Clinic in Munich,
has adopted a very ingenious device of wax
blocks, which he calls a "rav concentrator."

One set is arranged on either side of the
tube, and another at each side of the radiated
field, taking in the entire distance between
the skin and the tube. In this way he collects
or concentrates the rays of dispersion which
are then deflected to the center of the field,
and thus increases the radiation quotient
from 40 to 60 per cent. It becomes essential
therefore in order to reach the tumor with
the most favorable and suitable dosage quo-
tient, to increase the focal distance, to use
filtration of at least 0.5 mm, of copper or
zinc, and lastly to use as large a portal of
entry as the conditions permit.

Opitz of Freiburg has taken advantage of
all these factors which increase the dosage
quotient, in the treatment of carcinorna of
the uterus, first, by using a focal distance of
50 cm., and second, by enlarging the portal
to its maximum of 20 by 20 cm., and by
using I mm. of copper as a filter. In this
manner a skin erythema dose requires about
two hours, one application is administered
from the abdomen, one from the back, and
two from the side. Here also a minor detail
of refinement is made use of: the anterior
dose is administered so that the centralized
ray strikes the left edge of the tumor slightly
obliquely, and the posterior dose the right
edge of the tumor, in order to prevent
damage to the rectum, which is anatomically
situated to the left. The sum total of the
rays reaching the cancer mass in this manner
is very nearly a full cancer dose. To guard
against a sublethal dose to the interior of
the tumor, a small dose of radium is placed
in the uterus. Even if the cancer itself re-
ceives slightly more than a knockout dose,
the healthy adjacent tissue tolerates this and
thus escapes damage.

(

CHART HI

Dosage Quotient

• UNDER Three cm.

OF Tissue

Portal of Entry

Focal Distance

Qx 12 cm.

30 cm.

74%

10 X 15 cm.

50 cm.

86%

Qx 12 cm.

50 cm.

86%

15 x15 cm.

80 cm.

90%

9 X 12 cm.

100 cm.

90%

10 X 15 cm.

100 cm.

93%

The Newer Roentgen Therapy in Cancer

235

That intensive radiation lor short periods
is much more effective than smaller doses for
longer periods is pretty generally conceded,
and practical use is made of these patho-
logical and biological findings. It holds true
also, with small doses frequently repeated,
that the period of latency is considerably
protracted, and furthermore a cumulative
effect may be experienced producing chronic
changes which are not at all desirable, either
by stimulating the growth itself, or by dam-
aging the healthy tissue. Great stress is laid
upon the advisability of administering the
entire lethal dose at one sitting. There are.
however, times when the entire dose cannot
be administered in one day. The condition of
the patient or the danger of absorption tox-
emia may not admit of this. At any rate all
efforts should be directed to administering a
full lethal dose \vithin a week.

By way of summary I would like to draw
special attention to the following points:

It is most essential that sufficient intensive
roentgen or radium rays be administered to
knock out completely all parts of the cancer
without damaging or destroying adjacent
healthy tissue. If any one part of the tumor
receives a sublethal dose, failure and recur-
rence is sure to follow.

To effect the most favorable conditions of
radiation to the deeper tissues, proper filtra-
tion, increase in the focal distance, and in-
crease in the size of the portals of entry must
be made use of.

The determination of correct dosage com-
prises knowledge of the clinical location of
the tumor, its pathology, radiation dosage
quotient, and absorption coefficient.

From the personal application of this
technique in this short period of time, I gain
the impression that raying in the form of a
complete knockout dose administered at one
time will bring about better results in cancer
therapy.

CLINICAL RESULTS FROM THE NEWER TECHNIQUE OF
DEEP ROENTGENTHERAPY IN MALIGNANT DISEASES

By GEORGE E. PFAHLER, M.D.

PHILADELPHIA, PENNSYLVANIA

forty minutes will rarely give an erythema,
and that fifty minutes will generally give
an erythema. This technique has been de-
veloped gradually, in part by calculations and
in part by experimentation.

I would like to add a caution at the begin-
ning of this article and repeat it again at
the end: it is most important in every in-
stance before the current is turned on that
the filters be counted to make sure they are
in place, because if filtration is deficient this
prolonged treatment will produce an incur-
able burn. As a precaution against an acci-
dent I require that two people make observa-
tions on the filters for every dose given. If
the equipment is arranged for deep treatment
only, so that this one uniform technique is
used continually for all kinds of cases, then
the filters can be permanently put in place
and the precaution of counting will not be
necessary, but in the general roentgeno-
logical laboratory the apparatus must be used
for different purposes and lo millimeters of
filter is not always desirable, because it
wastes energy unnecessarily.

RELATIVE VALUE OF FILTERS

In order that our technique be made un-
derstandable it is necessary to know the rela-
ative value of various filters. Several years
ago, at one of these midwinter meetings of
this Society, I recommended the use of glass
instead of aluminum because the metal filters
frequently led to puncture of the Coolidge
tubes. From a scale furnished by the Radium
Chemical Company of Pittsburgh, I ob-
served that glass had approximately the same
filter value as aluminum. Therefore by using
glass we obtained a filter less likely to lead

'Read at the Midwinter Meeting of the Eastern Section of The American Roentgen Ray Society, Atlantic City, N. J.,

January 28, 29, 1921.

DURING September, 1920, Drs. Cool-
idge and Schmitz brought back to us
from Germany the information that in Ger-
many a greater amount of filtration was be-
ing used in the treatment of deep-seated ma-
lignant disease, with the source of rays at a
greater distance from the skin and with the
use of a higher voltage. The impression of
the few men who had the privilege of visit-
ing the German clinics was that more satis-
factory results were obtained from this
technique than from the lighter technique
used in this country. Our equipment in
America did not permit an exact duplication
of the technique used in Germany because
our apparatus as built to-day will not gener-
ate current at a voltage greater than 125,000,
or at most 130,000. It seemed important,
therefore, to see whether the technique
could be improved with our present appara-
tus and then perhaps later to determine
whether the results obtained by such im-
provement would correspond to the results
obtained in Germany. It is always- desirable
to proceed from the known to the unknown,
and instead of jumping wildly from one
technique into another of unknown quantity
and unknown value, I proceeded by calcula-
tions to transform my former technique for
deep roentgentherapy into my present tech-
nique. Generally my former technique con-
• sisted of 5 milliamperes of current at
126,000 volts, at a focal skin distance of
20 cm. filtered through 6 millimeters of
aluminum, for a period of 8 minutes. My
present technique consists of the use of
5 milliamperes at 126,000 volts, filtered
through 10 millimeters of aluminum or glass,
at a focal skin distance of 30 cm., for a
period of forty to fifty minutes. I find that

236

The Newer Technique of Deep Roentgen Therapy

237

to punctures of the tubes and that serves
ecjually well for filters. For this purpose the
ordinary glass used for photographic nega-
tives was cut to the proper size. First of all
we made a direct comparison of many layers
of this glass and in our own laboratory
found it to be uniform. I am told by Pro-
fessor Shearer that glass is not uniform in
its density, and therefore I caution others
against the use of glass until it has been
compared carefully with aluminum or some
other standard, after which I believe that it
can be used safely. For this purpose we took
10 millimeters of aluminum and 10 milli-
meters of glass and with the current such
as is used for treatment above described we
were able to prove that, at least so far as
the photographic values are concerned, the
two are equal. The exposures were made of
ys, Ya, /^, % and I second. In order to form
some idea of the relative value of filters such
as are used in Germany I then made a com-
parison photographically of copper and
aluminum. In Germany, as you will recall,
they are using from ^ to i millimeter of
copper as a filter. By my experiments I learn
that ^ millimeter of copper is equal to 13
millimeters of aluminum measured photo-
graphically.

With the above technique and with ex-
posures lasting from forty to fifty minutes
(and in a few cases I have given sixty
minutes), it is self-evident that it is undesir-
able from every standpoint to limit our field
of radiation to small areas such as we have
been doing in the past. I think most of us
have gradually increased the size of the field
of exposure. When we consider that the
smaller the field of radiation, the less the
amount of secondary radiation, and since
we must acknowledge that the secondary
radiation probably does as much as the pri-
mary radiation towards destroying malig-
nant disease, and in fact may be the sole
cause of destruction of the malignant cells,
the relative value of small areas and much
cross-firing decreases. It is always desirable
to cross-fire as much as possible providing
we are actually cross-firing, but mere divi-

sion of the surface of the body into small
areas, as I have often seen done, does not ac-
tually increase the cross-fire value. For ex-
ample, in the treatment of carcinoma of the
uterus, it is my practice to treat the local dis-
ease directly by radium and then to cross-fire
through an area extending from the svm-
physis pubis to the umbilicus and to the an-
terior superior spines on each side, and either
use this as one area for treatment or divide
it into two. Then a similar dose is given
through each lateral surface of the pelvis and
one or two similar areas posteriorly. In this
way all parts of the pelvis are irradiated and
I have seen some most brilliant results. For
example, a patient referred to me on Sep-
tember 30, 1920, by Dr. Wm. R. Nicholson,
was considered by him totally inoperable.
The entire cervix, including the walls of the
upper part of the vagina, were involved by
the carcinoma, making a total area of malig-
nant disease 7 or 8 cm. in diameter. She re-
ceived 4200 milligram hours of radium treat-
ment locally and two courses of .t'-ray treat-
ment consisting of four areas in each course
during six weeks. At the end of two and a
half months all evidence of disease had dis-
appeared. Even in recurrent disease about
the pelvis, with the above technique I have
obtained results that I have never seen
equalled by my former technique. In recur-
rent and metastatic disease of the breast and
in primary disease of the breast I have seen
results which are far superior to those ob-
tained by my former technique. In a few
primary cases that for some reason were
considered inoperable, I have seen all palp-
able evidence of malignant disease of the
breast including recurrent and metastatic
nodules, disappear more rapidly and more
satisfactorily than formerly. I have also seen
recurrent nodules disappear that gave no re-
sponse to the technique formerly used.

I think all of us have made the observation
in the treatment of malignant disease that
unless a pronounced primary effect is ob-
tained and the disease made to disappear
within a few months, it often develops a
resistance which is as great as that of the

238

The Newer Technique of Deep Roentgen Therapy

surrounding tissues, and therefore it requires
an amount of treatment necessary to destroy
the maHgnant disease such as will also des-
troy the surrounding healthy tissue. I be-
lieve, therefore, that it is desirable in all in-
stances to get as much treatment into the
malignant disease within the first month or
two as can be borne by the healthy tissues,
and in this way the malignant disease Is
destroyed while it is yet more sensitive to
radiation than the healthy tissue. For this
reason I dislike treating a patient who has
been inefficiently treated for several months
and then referred to me because the disease
has made progress.

Another phase of this newer deep roent-
gen therapy that cannot be ignored refers to
the radiation sickness. Those who give small
and frequent doses are less concerned about
the radiation sickness. There is, however,
nothing magical in anyone's technique with
regard to radiation sickness. It is probably
a measure of the amount of radiation and the
reaction of the tissues and the nervous sys-
tem therefrom. Those who give little radia-
tion will therefore have little radiation sick-
ness. We immediately found, therefore, that
as we increased the length of our exposures
we also increased the radiation sickness, both
in frequency and degree. We are hoping, by
careful study of the subject, to learn how to
overcome this condition ; but for the present
an increase of the interval between the treat-
ments or doses given has been found to be
our best safeguard. One cannot, however. I
believe, obtain the same results by too much
division of dosage; and if we use this deeper
technique and at the same time attempt to
give it in fractional doses, the expense
thereof will be correspondingly increased,
and unless most carefully managed may
allow the cancer cells to mature and develop
a orreater resistance to the ravs. As it is, the
expense of giving a dose of the deeper
therapy is greatly increased as compared
with the former technique. One must, there-
fore, keep the practical side in mind until
more powerful equipment is developed and

some means found of reducing the expense
due not so much to apparatus, electricity,
etc., as to human service.

With increase in the length of exposure
one also encounters the increased danger of
stray radiation and secondary radiation.
Therefore greater precautions are necessary
to guard against leaking tube shields, or any
other form of stray radiation. As a step in
this direction, I have designed the protecting
device previously described.^ If more power-
ful apparatus is developed w^e must also keep
in mind that with increased power comes
increased danger, which necessarily calls for
increased precautions.

I believe the technique above described to
be a definite advance. It will probably be fur-
ther modified and further developed, but so
far it is adaptable to our present outfits, and
if used with great caution greater beneficial
results can be obtained. I think we may draw
the following conclusions at present :

1. Increased filtration, with increased
focal skin distance, will increase the value
of deep radiation as compared to the surface
efifect.

2. Bv increasing the above two factors the
time of radiation is greatly increased — prob-
ablv five- fold. This prolonged radiation in
itself may be an important factor in pre-
venting cell division and regeneration of the
cancer cells.

3. Radiation sickness is increased, and
extra effort must be made to overcome this
efifect.

4. The greatest caution must be observed
in keeping the filters in place and at their
full prescribed quantity.

5. Increased protection is necessary for
both the patient and the operator.

6. The clinical results obtained from this
new deeper technique excel those obtained
formerly.

lA New Device for Increasing the Protection of
Both the Patient and the Roentgenologist. Presented
before the Philadelphia Roentgen Society January
13, 1921, and The American Roentgen Ray Society,
Atlantic City, N. J., January 29, 1921.

A NEW DEVICE FOR INCREASING THE PROTECTION

OF BOTH THE PATIENT AND THE

ROENTGENOLOGIST *

By GEORGE E. PFAHLER, M.D.

PHILADELPHIA, PENNSYLVANIA

ITH the increase of power in our ex-
citing apparatus there has been a
progressive increase in dangers to both the
patient and the roentgenologist. These dan-
gers consist primarily of injuries from the
high tension current to either patient or
roentgenologist, and secondarily and more
insidiously the dangers from strav radia-
tion. With the death of one physician and
two patients during the past two years from
accidental contact with the high tension cir-
cuit it is incumbent upon us to utilize every
means possible to eliminate such possibilities ;
and while the device which is here described
briefly and illustrated more particularly may
not give absolute security, it surely does give
increased protection. It is important to see.
of course, that there are no loose wires or
any that are likely to become loose ; but there
still remains the possibility that during an
examination a patient may bring some part
of his body within sparking distance of the
high tension current, and we know that when
the arc once starts through the air, which
ordinarily is an insulator, but which then
becomes a conductor, a large amount of cur-
rent can easily flow into the patient, and the
results above referred to indicate the danger.
The danger from stray radiation to both
the patient and the operator has increased
with the increased voltage and filtration.
While these stray rays are never as strong
as those applied directly to the part being
treated, as we increase the time of exposure
(which increases with the amount of filtra-
tion), any escape of stray rays through the
opening in the glass shields becomes a serious

the Philadelphia Roentgen Society, January 13,
Thf: American Roentge!* Ray Society.

danger to both patient and roentgenologist ;
and while the roentgenologist is farther
away than the patient, he is exposed to these
stray rays over so much longer period of
time that they become a danger to him. For
instance, most of us who are now using 5
milliamperes of current and 9 inch parallel
spark gap, can give an erythema dose of
unfiltered rays in approximately one minute
at a distance of 8 inches. With increased
filtration to 10 millimeters of aluminum and
increased distance to 12 inches the time is
increased to as much as fifty minutes and
therefore, even though only one-tenth or
one-hundredth as much radiation comes
through the opening in the glass bowl as is
passed through the opening in the dia-
phragm, it becomes a serious danger to both
the patient and the operator.

As a step towards overcoming these dan-
gers above described. I have made use of
opac[ue rubber which contains approximately
25 per cent of lead and which has an insulat-
ing value equivalent to a 4 inch spark. That
is, it will force a spark to leap around the
edge for a distance of 12 inches before
puncturing the rubber. But since the distance
from the terminal of the tube to the top
of the rubber is only 8 inches the actual
insulation value is only about 4 inches, be-
cause the current tends to creep along the
rubber to about one half the air spark re-
sistance. The rubber is about 3 millimeters
thick, and is sold as Hercules red rubber
packing. A piece of this rubber, 12 inches by
18 inches, is attached to the base of the
diaphragm and is then curved over the ends

g-'i, anl "t the Midwinter Meeting of the Eastern Section of
Atlantic City, N. J., January 28, 29, 1921.

240

A New Device for Increased Protection

Fig. a (above). Lateral View, showing the opaque
lead rubber curved aliout the ends of the tube and
closing off the line of radiation through the open-
ings in the tube, (i) The opaque rubber. (2) Re-
inforcement layer. (3) Springs and hooks holding
the top of the lead rubVier together across the top
of the lead glass shield.

Fig. B (middle). Front view of protective shield.

Fig. C (beloz^'). Top view of protective shield.

of the tubes and the wires, and is folded back
towards the glass bowl so as to cover both
the front and the back and at the same time
to carry the wires upward 8 inches. The cen-
tral portion of this rubber directly in front
of the terminals of the tube is reinforced by
another thickness of this rubber, 6 inches by
6 inches, which increases the insulation and
increases the protection against the roentgen
ray. The upper ends of this rubber are
fastened together by cords and small hooks
so that they can be easily released when
it is necessary to change the tube. The chang-
ing of tubes is fortunately not so frequent
as was necessary with the old type of gas
tube, and therefore the inconvenience of
making these connections is of secondary im-
portance. This rubber protection can be
adapted to any type of tube holder. At least,
we have adapted it to six different types used
in our laboratory and while I am only illus-
- trating one, a little ingenuity on the part of
the roentgenologist or a mechanic will enable
him to adapt the device to anyone's use.
The photographs have been made in three
different views and I think illustrate the
attachment and application better than I can
do by description. On one tube stand we have
found an advantage in extending the cords
over a cross-piece resting on two posts which
fit over the rim of the glass bowl or shield.
This carries the support higher and makes
the tension less upon the .terminals of the
tube.

This protecting device moves easily with
the tube holder and glass shield and is no
inconvenience. While it does not give abso-
lute protection either against the high ten-
sion electric current, or the radiation, it is a
good step in the right direction.

X-RAY TREATMENT OF PULMONARY TUBERCULOSIS*

By will WILKINSON, M.D.

PHOEXIX. ARIZONA

FOR the past decade jr-ray men have been
the cavalry of the great and splendid
army of medical men, and I appreciate the
honor of being made a member of a society
all of whom are imbued with the "let's go"
spirit.

It occurred to me that in one respect I
am treading in the path of my illustrious
confrere and fellow-townsman, Dr. Warner
Watkins, who usually starts something
whenever he appears before you. It is a little
surprising that .r-ray therapy is a recognized
treatment for glandular, bone, skin and peri-
toneal tuberculosis, but has l:)een so little
applied in chronic lung trouble. The sub-
sternal lymph glands are usually the primary
foci of infection, and the arrest of the
disease is complete or partial in proportion to
the fibrosis and calcification of chest lymph
glands. Careful workers have very generally
reported success in the treatment of tuber-
culous cervical glands. Why not give tuber-
culous bronchial glands the same treatment?

The proven value of the .r-ray s in unre-
solved pneumonia has established its place
in the treatment of this disease of the chest.
Furthermore, it is admitted that it is the
actinic rays of the sun that are responsible
for the brilliant results of solar therapy in
all forms of tuberculous infection. Also we
now know that the sun's rays are physically
the same as .r-ray s, only much softer. I
believe the greater penetration of .t"-rays
makes them especially valuable in the treat-
ment of deep-seated tuberculous foci in the
lungs, and that we are really putting sun-
shine inside the chest.

Dr. J. D. Gibson, of Denver, was one of
the pioneers in .r-ray therapy : he gives this
remedv the foremost place in the complete
arrest of his own lung disease some twenty
years ago. Since that time he has had a very

large clinical experience with .r-ravs in oflice
treatment of consumptives. After being in
general practice in Phoenix, where about
half my work was with tuberculous patients,
I had the opportunity of \ isiting Dr. Gibson.
He showed me a large number of chest plates
of his patients, and, with few exceptions, the
cases that persisted in the treatment showed
marked reduction in the substernal gland
shadows. As I went over his case records
and interviewed his patients, I was con-
\inced that they improved in appetite, weight
and strength much more rapidly than mv
own tuberculous patients, or those of anv
practitioner with whose work I was familiar.

In a recent article. Dr. Gibson says: 'The
fact is, the .r-ray is probably the greatest
blessing ever bestowed in one agent upon
suft'ering humanity through the medical pro-
fession. A-ray diagnosis has saved its thous-
ands, but radiotherapy when properlv recog-
nized will save its millions. It has a range
of therapeutic effect from producitig the
gentle stimulation with slight hyperemia, on
to over-stimulation and inhibition, until de-
struction of tissues results."

Again, from the same paper: "I made the
claim many years ago that the opsonic index
should be controlled and regulated by means
of the .r-ray. Dr. Crane, of Kalamazoo, and
Dr. ^[cCullough. of Londoti, have sustained
this contention. Later, I ascertained that
with the hyperemia and engorgement pro-
duced in tissues by means of the .r-ray,
changes developed in the tissues which had
for their final effect the creation of homo-
logous vaccine from the antigens developed
within the patients' own tissues. These vac-
cines, antitoxins and antibodies, generated in
Nature's own wav, give us a most ideal
autogenous vaccine."

Other writers have called attention to the

'Read liefore the joint meeting of the Pacific Coast Roentgen Ray Society and the Western Section of The American
Roentgen Ray Society, at Avalon. Catalina Island. California, June 19, 1920.

241

242

.Y-Ray Treatment of Pulmonary Tuberculosis

improvement in lung trouble when only the
cervical glands were being rayed, and at-
tributed the benefit to autogenous vaccina-
tion from the cervical glands. Dr. Gibson
gives a series of blood counts made on a
number of cases which show a decided in-
crease in the mononuclear cells.

A very interesting paper, entitled "Experi-
mental Studies with Small Doses of X-Ray,"
appeared in the Lancet of April 26, 191 9.
Dr. Russ and his coworkers studied their
effects upon the blood and found the mono-
nuclears more markedly affected than the
reds or polynuclears. I quote at some length
his results:

"We have obtained identical results upon
the lymphocytes with unscreened medium
;r-rays and with very hard rays screened by
7 mm. of aluminum.

"From the results of many experiments
devised to determine the nature of the action
of the .r-rays on the lymphocytes, it has been
concluded that the action is a direct one upon
these cells in circulation. One such experi-
ment was as follows -.

"A rat completely screened by lead except
for a region over the heart, was exposed to
a parallel beam of .r-rays; the exposure was
adjusted so that the circulating blood should
receive the same amount of .t'-ravs as it
would by exposing the whole animal for
about one minute. The fall and recoverv
curves of the lymphoc\'tes were obtained and
charted. They were nearly identical.

"The fact that the lymphocvtes disappear
from the circulation in such large numbers
after an exposure lasting but two seconds
leads us to doubt very stronglv that this is
due to their destruction, especiallv as thev
reappear with great rapidity. It is not a
direct local effect of the radiation upon the
tissues, for no local accumulation occurs in
the irradiated area, nor have we detected anv
alteration in the general distribution of the
lymphocytes through the lungs, liver or kid-
neys, as they have been examined from this
point of view.

"If lymphocytes in vitro be given a dose
one thousand times as large as that required
for these effects in vivo, no degenerative

changes are detectable microscopically and
no diminution in their numbers is observed.

"A rat, when given a small dose of .r-rays
(twelve seconds) shows a 50 per cent reduc-
tion of its circulating lymphocytes one hour
later; then it begins to recover and in
twenty- four or forty-eight hours is normal
again. If the same dose is administered a
fortnight later, a similar drop occurs, the re-
covery is slightly delayed, but the numbers
of lymphocytes finally reached is generally
greater than at the beginning. Repeated ap-
plication of such a small dose may result in a
high degree of lymphocytosis. The circulat-
ing lymphocytes in the two cases depicted
have increased from 11,000 and 25,000 to
112,000 and 117,000 per cm. respectively;
corresponding counts for the polynuclear
leucocytes were initially 5,000 and 5,000,
terminating in 10,000 and 14,000 per cm.
respectively.

"There is clear evidence of instability in
the blood contents of these irradiated ani-
mals, but the number of lymphocytes rarely
drops so low as the normal level, even several
months after the exposures have ceased.

"Exactly what are the best radiation con-
ditions for the production of this lymphocy-
tosis it is not yet possible to say. Large doses
may eventually produce the condition, but
are to be avoided, owing to their injurious
nature. It is uncertain, at present, whether
a small dose repeated at very short intervals
produces the result. One batch of eleven
animals was given small daily doses (twelve
seconds) over a period of two months. The
average of the lymphocyte counts before ir-
radiation was 19,000; three days after the
last dose of .r-rays, it was 27.000, and no
marked rise was detected later, although
counts were made upon some of the animals
for another two months.

"It has been shown in a previous publica-
tion by two of us that when sarcoma cells
(Jensen's rat sarcoma) are inoculated into
rats wliich had been previouslv immunized,
the failure of the sarcoma to grow is asso-
ciated with some special activity on the part
of the lymphocytes.

"The further experimental fact acquired

X-Ray Treatment of Pulmonary Tuberculosis

243

was that if immune rats were given a dose of
;ir-rays sufficiently large to cause and main-
tain a marked lymphopenia, then such im-
mune animals became once more susceptible
to the growth of the sarcoma."

X-ray workers have become sterile, and
we are able to induce the menopause and
sterility in women, whenever indicated. It
may be that the reproductive power of the
tubercle bacillus is reduced by the Gibson
method of .r-ray treatment and its virulence
destroyed.

During the past seven years, I have been
treating consumptives with .;r-rays and most
of them were decidedly benefited. I have also
had a good success in relieving winter
coughs which would not respond to cough
mixtures. Three to six exposures on alter-
nate days are usually sufficient in these cases.

As an illustration, I cite the case of a
young mining engineer who for four years
after coming to Arizona did not improve
greatly and was unable to work. In the fall
of 1913, I gave him a three months' course
of .r-ray treatment. There was marked im-
provement in cough, and pulse dropped to
eighty ; by early spring he went to work and
has not lost much time since. Last fall and
winter he took another course of treatment,
of five months' duration, with decided bene-
fit in his general condition. The radiographs
of his chest showed marked increase in peri-
bronchial fibrosis, with scattered areas of
calcification and diminution in the width of
the hilus shadow.

TECHNIQUE

We give treatments three times a week,
alternately exposing the anterior and the

posterior chest, using 2 to 3 ma., 6 in. spark,
15 in. distance, 5 to 10 minutes time, and
3 mm. of aluminum as filter. In many cases,
we begin with a dose somewhat less than
the above, especially if the case has rapid
heart and slight temperature, applying the
lesson taught by heliotherapy, that the tu-
berculous patient must begin with very short
sun baths.

To sum up, we believe that when jr-ray
therapy is properly used in incipient tubercu-
losis, especially with those who have im-
proved or are at a standstill, most of them
will be decidedly benefited. As in pneumonia,
inflammation and conges

Internet Archive Audio

Featured

Top

Images

Featured

Top

Software

Featured

Top

Books

Featured

Top

Video

Featured

Top

Mobile Apps

Browser Extensions

Archive-It Subscription

Save Page Now

Full text of "The American journal of roentgenology, radium therapy and nuclear medicine"

See other formats